Provider Demographics
NPI:1376535393
Name:GREEN, NICHOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1513
Mailing Address - Country:US
Mailing Address - Phone:716-372-0141
Mailing Address - Fax:716-372-6421
Practice Address - Street 1:535 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1513
Practice Address - Country:US
Practice Address - Phone:716-372-0141
Practice Address - Fax:716-372-6421
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0315Medicare ID - Type Unspecified
NYP44947Medicare UPIN