Provider Demographics
NPI:1225650849
Name:NISTICO, MARK (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:NISTICO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MAYAPPLE WAY
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4390
Mailing Address - Country:US
Mailing Address - Phone:518-818-4492
Mailing Address - Fax:
Practice Address - Street 1:23 MAYAPPLE WAY
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4390
Practice Address - Country:US
Practice Address - Phone:518-818-4492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY623-121163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice