Provider Demographics
NPI:1093104879
Name:CICCONE, NICHOLAS GIACOMO (MSPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GIACOMO
Last Name:CICCONE
Suffix:
Gender:M
Credentials:MSPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 BEANER HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-9722
Mailing Address - Country:US
Mailing Address - Phone:724-775-4242
Mailing Address - Fax:724-775-4960
Practice Address - Street 1:1030 BEANER HOLLOW RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9722
Practice Address - Country:US
Practice Address - Phone:724-775-4242
Practice Address - Fax:724-775-4960
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061397363A00000X
2255A2300X
SC2845363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3416PAMedicaid
SCSCB7227628OtherMEDICARE PIN