Provider Demographics
NPI:1164919320
Name:ILASI, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ILASI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2469 STATE ROUTE 19 N
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-9336
Mailing Address - Country:US
Mailing Address - Phone:585-786-8505
Mailing Address - Fax:
Practice Address - Street 1:217 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1613
Practice Address - Country:US
Practice Address - Phone:585-345-1147
Practice Address - Fax:585-345-1187
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003394-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician