Provider Demographics
NPI:1720551229
Name:GARDOCKI, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:GARDOCKI
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 1:15 ANITA PL
Mailing Address - Street 2:
Mailing Address - City:AMITY HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11701-4101
Mailing Address - Country:US
Mailing Address - Phone:631-662-1089
Mailing Address - Fax:
Practice Address - Street 1:389 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-2723
Practice Address - Country:US
Practice Address - Phone:516-867-5132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023060-1207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine