Provider Demographics
NPI:1497122170
Name:WIZEL, NICOLE TESSA (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:TESSA
Last Name:WIZEL
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 1:17660 UNION TPKE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1526
Mailing Address - Country:US
Mailing Address - Phone:718-460-2300
Mailing Address - Fax:
Practice Address - Street 1:17660 UNION TPKE
Practice Address - Street 2:SUITE 360
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1526
Practice Address - Country:US
Practice Address - Phone:718-460-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical