Provider Demographics
NPI:1497930531
Name:NICO PA PC
Entity Type:Organization
Organization Name:NICO PA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:N
Authorized Official - Last Name:NICOLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-388-7644
Mailing Address - Street 1:127 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-4006
Mailing Address - Country:US
Mailing Address - Phone:917-388-7644
Mailing Address - Fax:
Practice Address - Street 1:14 KIRKWOOD RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-1437
Practice Address - Country:US
Practice Address - Phone:917-388-7644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009001363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty