Provider Demographics
NPI:1558880815
Name:IZZO, NICKOLAS (PA)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:
Last Name:IZZO
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:301 PROSPECT AVE RM 1605
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5100 W TAFT RD STE 1D
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3808
Practice Address - Country:US
Practice Address - Phone:315-744-1833
Practice Address - Fax:315-452-2336
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant