Provider Demographics
NPI:1568960078
Name:BROUGHTON, NICHOLAS EDWARD (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:BROUGHTON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:26 PARKVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-2310
Mailing Address - Country:US
Mailing Address - Phone:516-640-8516
Mailing Address - Fax:
Practice Address - Street 1:99 WOODBURY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3043
Practice Address - Country:US
Practice Address - Phone:516-595-7454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY021545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant