Provider Demographics
NPI:1376328773
Name:INOCENCIO, NICKO (PA)
Entity Type:Individual
Prefix:
First Name:NICKO
Middle Name:
Last Name:INOCENCIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 DEN LEE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-9711
Mailing Address - Country:US
Mailing Address - Phone:240-640-4989
Mailing Address - Fax:
Practice Address - Street 1:1 CAPITAL WAY
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2520
Practice Address - Country:US
Practice Address - Phone:609-303-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00792900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant