Provider Demographics
NPI:1770949901
Name:LUONGO, NICOLE L (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:LUONGO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-0350
Mailing Address - Country:US
Mailing Address - Phone:215-723-2333
Mailing Address - Fax:215-257-1800
Practice Address - Street 1:325 CENTRAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3265
Practice Address - Country:US
Practice Address - Phone:610-644-6755
Practice Address - Fax:610-647-2063
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA057902363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical