Provider Demographics
NPI:1265561435
Name:DOUROUDAKIS, NICKIE (PA)
Entity type:Individual
Prefix:
First Name:NICKIE
Middle Name:
Last Name:DOUROUDAKIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22112 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1930
Mailing Address - Country:US
Mailing Address - Phone:917-453-8024
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTHERN BLVD STE 121
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1220
Practice Address - Country:US
Practice Address - Phone:516-705-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008029363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical