Provider Demographics
NPI:1912370305
Name:NICOLOFF, JEREMY (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:NICOLOFF
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 AIRPORT BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-2048
Mailing Address - Country:US
Mailing Address - Phone:650-240-8198
Mailing Address - Fax:
Practice Address - Street 1:1501 TROUSDALE DR FL 1
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4506
Practice Address - Country:US
Practice Address - Phone:650-652-8700
Practice Address - Fax:650-652-8705
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52946363AS0400X
FLPA9109218363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical