Provider Demographics
NPI:1467073635
Name:CUSUMANO, NICOLE JOANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JOANN
Last Name:CUSUMANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 CARLYLE GRN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1719
Mailing Address - Country:US
Mailing Address - Phone:646-784-0120
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant