Basic Information
| Provider Information | |||||||||
| NPI: | 1255802567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LA MARQUE | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1783 ROUTE 9 STE 202 | ||||||||
| Address2: | |||||||||
| City: | HALFMOON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183832366 | ||||||||
| FaxNumber: | 5183836022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2018 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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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 | 363A00000X | 023055 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.