Provider Demographics
NPI:1679771166
Name:MEDRANO, NICOLA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLA
Middle Name:MARIE
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:PA-C
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
Mailing Address - Street 2:BOX 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-342-5155
Mailing Address - Fax:212-305-1163
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:8 SOUTH KNUCKLE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-5138
Practice Address - Fax:212-305-1163
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant