Provider Demographics
NPI:1467962597
Name:DOUR, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:DOUR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 KENTAL LN
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1511
Mailing Address - Country:US
Mailing Address - Phone:516-233-0657
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL RD STE 200
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-8814
Practice Address - Country:US
Practice Address - Phone:631-307-9737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant