Provider Demographics
NPI:1790765741
Name:BRONG, NYCOLE (PA)
Entity Type:Individual
Prefix:
First Name:NYCOLE
Middle Name:
Last Name:BRONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NYCOLE
Other - Middle Name:
Other - Last Name:AGNELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:462 GRIDER ST
Mailing Address - Street 2:ERIE COUNTY MEDICAL CENTER
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3021
Mailing Address - Country:US
Mailing Address - Phone:716-898-3525
Mailing Address - Fax:
Practice Address - Street 1:207 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2302
Practice Address - Country:US
Practice Address - Phone:716-689-1901
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02343795Medicaid
NYCC7168Medicare ID - Type Unspecified