Provider Demographics
NPI:1316203318
Name:VAVRINA, NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VAVRINA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 SULLYS TRL
Mailing Address - Street 2:STE 100
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-4567
Mailing Address - Country:US
Mailing Address - Phone:585-758-0800
Mailing Address - Fax:585-381-1577
Practice Address - Street 1:167 SULLYS TRL
Practice Address - Street 2:STE 100
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-4567
Practice Address - Country:US
Practice Address - Phone:585-758-0800
Practice Address - Fax:585-381-1577
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04503962Medicaid
NYJ400334373Medicare PIN