Provider Demographics
NPI:1477264786
Name:RICO, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RICO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319 S MANNING BLVD STE 206
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1743
Practice Address - Country:US
Practice Address - Phone:518-525-8501
Practice Address - Fax:518-525-8503
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
NY031963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist