Provider Demographics
NPI:1740422336
Name:ANTZOULIDES CONROE, NICOLE MARIA (PA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIA
Last Name:ANTZOULIDES CONROE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIA
Other - Last Name:ANTZOULIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3680 EGGERT RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3680 EGGERT RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1963
Practice Address - Country:US
Practice Address - Phone:716-662-5357
Practice Address - Fax:716-662-2774
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013201-1363AM0700X
NY013201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013201OtherNYS LICENSE