Provider Demographics
NPI:1477551620
Name:FUSCO, NICHOLAS EDWARD (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:FUSCO
Suffix:
Gender:M
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 1:391 GEORGE W LILES PKWY NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8218
Mailing Address - Country:US
Mailing Address - Phone:704-886-1780
Mailing Address - Fax:704-918-4505
Practice Address - Street 1:391 GEORGE W LILES PKWY NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8218
Practice Address - Country:US
Practice Address - Phone:704-886-1780
Practice Address - Fax:704-918-4505
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002789L363AM0700X, 363AS0400X
NC0010-10044363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA169767EDCMedicare PIN