Provider Demographics
NPI:1427223494
Name:GERAGHTY, NICOLE (R PA C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GERAGHTY
Suffix:
Gender:F
Credentials:R PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 VETERANS HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7640
Mailing Address - Country:US
Mailing Address - Phone:631-676-7656
Mailing Address - Fax:631-676-7648
Practice Address - Street 1:3505 VETERANS HWY
Practice Address - Street 2:SUITE C
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7640
Practice Address - Country:US
Practice Address - Phone:631-676-7656
Practice Address - Fax:631-676-7648
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP16322Medicare UPIN