MEDICARE: MISS NICOLE BELLA GLUSHANOK 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	031429	NY
2	363A00000X	Physician Assistant	031429-01	NY

General Provider Information

NPI Number	:	1639936164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NICOLE BELLA GLUSHANOK PA

Provider Business Mailing Address
First Line	:	242 GREENGROVE AVE
Second Line	:
City	:	UNIONDALE
State	:	NY
Zip	:	11553-1517
Country	:	US
Telephone Number	:	551-579-9271
Fax Number	:

Provider Business Practice Location Address
First Line	:	1041 47TH AVE
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5416
Country	:	US
Telephone Number	:	551-579-9271
Fax Number	:

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

Provider Enumeration Date	:	03/01/2024
Last Update Date	:	06/12/2024

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