Provider Demographics
NPI:1639936164
Name:GLUSHAANOK, NICOLE BELLA (PA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:BELLA
Last Name:GLUSHAANOK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:242 GREENGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-1517
Mailing Address - Country:US
Mailing Address - Phone:551-579-9271
Mailing Address - Fax:
Practice Address - Street 1:1041 47TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5416
Practice Address - Country:US
Practice Address - Phone:551-579-9271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031429363A00000X
NY031429-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant