Provider Demographics
NPI:1275807448
Name:HERNANDEZ, NICOLE (RPA-C)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HWY BLDG 15H
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2554
Mailing Address - Country:US
Mailing Address - Phone:631-689-3005
Mailing Address - Fax:631-689-1750
Practice Address - Street 1:2500 NESCONSET HWY BLDG 15H
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2554
Practice Address - Country:US
Practice Address - Phone:631-689-3005
Practice Address - Fax:631-689-1750
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant