Provider Demographics
NPI:1033546437
Name:BASEIL, NICOLE ANNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ANNE
Last Name:BASEIL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 ELSTON DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-413-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017054363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical