Provider Demographics
NPI:1497748453
Name:NICOLSON, LYNNE T (MD)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:T
Last Name:NICOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:1270 BELMONT AVE
Practice Address - Street 2:SUITE 259
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2104
Practice Address - Country:US
Practice Address - Phone:518-382-4560
Practice Address - Fax:518-386-3619
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160933204C00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB82814Medicare ID - Type Unspecified