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General NPI Number Information
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NPI Number | 1720551229
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Entity Type | Individual
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Provider Name | NICOLE MARIE GARDOCKI PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/07/2019
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Last Update Date | 01/07/2019
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Provider Practice Location Address
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Address Line | 389 MERRICK AVE
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City | MERRICK
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State | NY
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Zip | 11566-2723
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Country | US
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Telephone | 516-867-5132
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Fax |
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Provider Business Mailing Address
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Address Line | 15 ANITA PL
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City | AMITY HARBOR
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State | NY
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Zip | 11701-4101
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Country | US
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Telephone | 631-662-1089
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 023060-1
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License Number State | NY
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