Provider Demographics
NPI:1225422454
Name:SAMPLE-HARRIS, NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SAMPLE-HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27005 76TH AVE STE C221
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1496
Mailing Address - Country:US
Mailing Address - Phone:718-470-7660
Mailing Address - Fax:718-962-6739
Practice Address - Street 1:1300 UNION TPKE STE 301
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:516-616-1300
Practice Address - Fax:718-271-1159
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297465-1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology