Provider Demographics
NPI:1730129974
Name:RILEY, NICOLE (PA, C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:PA, C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 EVES DR # A
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3195
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:609-267-9457
Practice Address - Street 1:401 YOUNG AVE
Practice Address - Street 2:SUITE 245
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3130
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:609-267-9457
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP44191Medicare UPIN
NJ137317Medicare ID - Type Unspecified