Provider Demographics
NPI:1760769509
Name:PISCIOTTA, NICOLE MARY (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARY
Last Name:PISCIOTTA
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:363-774-0044
Mailing Address - Fax:336-277-4349
Practice Address - Street 1:2337 WINTERHAVEN LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6792
Practice Address - Country:US
Practice Address - Phone:336-774-0044
Practice Address - Fax:336-277-4349
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2024-05-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY015270-1363A00000X
NC0010-03589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant