MEDICARE: MS. NICOLE C FALLACARO PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	010718	NY
2	363A00000X	Physician Assistant	4453	AZ

General Provider Information

NPI Number	:	1174582290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE C FALLACARO PA

Provider Business Mailing Address
First Line	:	7095 S FAWN AVE
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85298-9274
Country	:	US
Telephone Number	:	718-702-4796
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 S VAL VISTA DR
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85295-1675
Country	:	US
Telephone Number	:	480-324-0300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2006
Last Update Date	:	12/28/2011

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