Healthcare Provider Details

I. General information

NPI: 1104741891
Provider Name (Legal Business Name): ANDREW NICOSIA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 LYNBROOK DR
TONAWANDA NY
14150-4222
US

IV. Provider business mailing address

15 LYNBROOK DR
TONAWANDA NY
14150-4222
US

V. Phone/Fax

Practice location:
  • Phone: 716-308-7307
  • Fax:
Mailing address:
  • Phone: 716-308-7307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number104753I
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: