Basic Information
| Provider Information | |||||||||
| NPI: | 1053496422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 979 CROSS BRONX EXPY | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104604885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186657565 | ||||||||
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| Practice Location | |||||||||
| Address1: | 178 SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115704704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165365765 | ||||||||
| FaxNumber: | 5165365766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 207843 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |