Provider Demographics
NPI:1669627832
Name:MASSARO, NICOLE (R-PAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MASSARO
Suffix:
Gender:F
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-4906
Mailing Address - Country:US
Mailing Address - Phone:631-241-6603
Mailing Address - Fax:
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant