Provider Demographics
NPI:1366688913
Name:PATINO, NICOLE A (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:A
Last Name:PATINO
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:PO BOX 6002 -NCW-4
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-326-2856
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:4TH FLOOR PARKINSON SUITE# 451
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT193961208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3270668Medicare PIN