Provider Demographics
NPI:1497478994
Name:SUCH, NICOLE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SUCH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 LEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-1424
Mailing Address - Country:US
Mailing Address - Phone:585-794-6824
Mailing Address - Fax:
Practice Address - Street 1:2400 S CLINTON AVE STE 110
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2668
Practice Address - Country:US
Practice Address - Phone:585-341-7141
Practice Address - Fax:585-461-4426
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant