Provider Demographics
NPI:1669415576
Name:NIZIOLEK, ANDREA MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:NIZIOLEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:FORGIONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:20 YORK STREET, CB-2041
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-4748
Mailing Address - Fax:203-688-4740
Practice Address - Street 1:20 YORK STREET, CB-2041
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:203-688-4740
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001752363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400000053Medicare PIN
CTQ64864Medicare UPIN