Provider Demographics
NPI:1609421940
Name:BURRY, NICOLAS
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:BURRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W 168TH ST # 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-305-0591
Mailing Address - Fax:212-305-6891
Practice Address - Street 1:161 FT WASHINGTN AVE FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-0591
Practice Address - Fax:212-305-6891
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF344770-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily