Provider Demographics
NPI:1770238248
Name:MCGILLICUDDY, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MCGILLICUDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2733
Mailing Address - Country:US
Mailing Address - Phone:585-341-0901
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2733
Practice Address - Country:US
Practice Address - Phone:585-341-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29144363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program