Basic Information
| Provider Information | |||||||||
| NPI: | 1285753954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PASTORE | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8173 WHITMAN WAY | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130906894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153457034 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7375 OSWEGO RD | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130903717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152910064 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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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 | 008744-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02882277 | 05 | NY | MEDICAID |