Provider Demographics
NPI:1710347620
Name:CONSTANTINO, NICHOLAS EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:CONSTANTINO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WAYMONT CT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3485
Mailing Address - Country:US
Mailing Address - Phone:407-323-3550
Mailing Address - Fax:407-322-6127
Practice Address - Street 1:410 WAYMONT CT
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3485
Practice Address - Country:US
Practice Address - Phone:407-323-3550
Practice Address - Fax:407-322-6127
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant