MEDICARE: NICOLE ROSE MARINO PA-C

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	20058	NY
2	363AM0700X	Medical Physician Assistant	20058	NY
3	363AS0400X	Surgical Physician Assistant	20058	NY

General Provider Information

NPI Number	:	1467904508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ROSE MARINO PA-C

Provider Business Mailing Address
First Line	:	7943 211TH ST
Second Line	:
City	:	HOLLIS HILLS
State	:	NY
Zip	:	11364-3225
Country	:	US
Telephone Number	:	646-530-1480
Fax Number	:

Provider Business Practice Location Address
First Line	:	7943 211TH ST
Second Line	:
City	:	HOLLIS HILLS
State	:	NY
Zip	:	11364-3225
Country	:	US
Telephone Number	:	646-530-1480
Fax Number	:

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

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	10/25/2016

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