Provider Demographics
NPI:1518395078
Name:DIMARCO, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:DIMARCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:REBOCHAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:970 MAPLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-0912
Mailing Address - Country:US
Mailing Address - Phone:954-591-3966
Mailing Address - Fax:
Practice Address - Street 1:1330 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1402
Practice Address - Country:US
Practice Address - Phone:814-459-9300
Practice Address - Fax:814-456-5145
Is Sole Proprietor?:No
Enumeration Date:2013-10-21
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010659800Medicaid
FLHS210ZOtherMEDICARE PTAN
FLHS210ZMedicare PIN