Provider Demographics
NPI:1063660983
Name:CARRILLO, NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:FRIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:377 JERSEY AVE STE 450
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-4397
Mailing Address - Country:US
Mailing Address - Phone:201-915-2525
Mailing Address - Fax:
Practice Address - Street 1:377 JERSEY AVE STE 450
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4397
Practice Address - Country:US
Practice Address - Phone:201-915-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00203400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00203400OtherLICENSE