Provider Demographics
NPI:1710993449
Name:NICOLO, ENRICO (MD)
Entity Type:Individual
Prefix:DR
First Name:ENRICO
Middle Name:
Last Name:NICOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 STOOPS DRIVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MONONGAHELA
Mailing Address - State:PA
Mailing Address - Zip Code:15063-3556
Mailing Address - Country:US
Mailing Address - Phone:724-483-3639
Mailing Address - Fax:724-483-3758
Practice Address - Street 1:100 STOOPS DR
Practice Address - Street 2:SUITE 230
Practice Address - City:MONONGAHELA
Practice Address - State:PA
Practice Address - Zip Code:15063-3553
Practice Address - Country:US
Practice Address - Phone:724-483-3639
Practice Address - Fax:724-483-3758
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038722L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009697470002Medicaid
PA0009697470002Medicaid
PAC29160Medicare UPIN