MEDICARE: NICO PA PC

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	363AS0400X	Surgical Physician Assistant	009001	NY

General Provider Information

NPI Number	:	1497930531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICO PA PC

Provider Business Mailing Address
First Line	:	127 S BROADWAY
Second Line	:
City	:	YONKERS
State	:	NY
Zip	:	10701-4006
Country	:	US
Telephone Number	:	917-388-7644
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 KIRKWOOD RD
Second Line	:	2ND FLOOR
City	:	PORT WASHINGTON
State	:	NY
Zip	:	11050-1437
Country	:	US
Telephone Number	:	917-388-7644
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETER
Name	:	NICK N NICOLOFF
Credential	:
Telephone Number	:	917-388-7644

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	01/08/2008

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