Provider Demographics
NPI:1942337514
Name:SPANO, NICHOLAS S (NP)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:S
Last Name:SPANO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:29 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-3612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 UNION AVE
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-3324
Practice Address - Country:US
Practice Address - Phone:631-878-0310
Practice Address - Fax:631-878-0754
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304217363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ55186Medicare UPIN