Provider Demographics
NPI:1801830013
Name:MCNICHOLAS, PENELOPE A (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:PENELOPE
Middle Name:A
Last Name:MCNICHOLAS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:MS
Other - First Name:PENELOPE
Other - Middle Name:A
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 HICKSVILLE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-3471
Mailing Address - Country:US
Mailing Address - Phone:516-576-5812
Mailing Address - Fax:516-576-5801
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-2727
Practice Address - Fax:516-663-8549
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP66231Medicare UPIN