Provider Demographics
NPI:1730284241
Name:NIKONCHIK, ANDREA SUZANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:SUZANNE
Last Name:NIKONCHIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 POWERS BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5464
Mailing Address - Country:US
Mailing Address - Phone:440-845-1500
Mailing Address - Fax:
Practice Address - Street 1:6707 POWERS BLVD
Practice Address - Street 2:STE 203
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5455
Practice Address - Country:US
Practice Address - Phone:440-845-1500
Practice Address - Fax:440-845-9227
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062599208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0848579Medicaid
OH1730284241Medicaid
ZE4208731Medicare PIN