Provider Demographics
NPI:1497389621
Name:LAROSA, NICOLETTE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:NICOLETTE
Middle Name:
Last Name:LAROSA
Suffix:
Gender:F
Credentials:PA-C
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:3 RAVDIN BLDG STE F
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-3202
Mailing Address - Fax:215-349-8432
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:3 RAVDIN BLDG STE F
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-3202
Practice Address - Fax:215-349-8432
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA062445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant