Basic Information
| Provider Information | |||||||||
| NPI: | 1356784839 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TETREAULT | ||||||||
| FirstName: | NICOLE | ||||||||
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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: | 3757 CARMAN RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123035438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183557063 | ||||||||
| FaxNumber: | 5183570646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 284361 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04849969 | 05 | NY | MEDICAID | 5915911 | 01 | NY | AETNA | OTHER | J400411668 | 01 | NY | MEDICARE | OTHER | 8592D1 | 01 | NY | EMPIRE BLUECROSS BLUESHIELD | OTHER |