Provider Demographics
NPI:1336437722
Name:WRIGHT, NICOLE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:F
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 1:1503 METROPOLITAN AVE APT 1A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6150
Mailing Address - Country:US
Mailing Address - Phone:718-828-7965
Mailing Address - Fax:
Practice Address - Street 1:1503 METROPOLITAN AVE APT 1A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-6150
Practice Address - Country:US
Practice Address - Phone:718-828-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant