Basic Information
| Provider Information | |||||||||
| NPI: | 1497734883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOTRA | ||||||||
| FirstName: | PRISCILLA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5008 BRITTONFIELD PKWY | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130579248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727504 | ||||||||
| FaxNumber: | 3154798639 | ||||||||
| Practice Location | |||||||||
| Address1: | 5008 BRITTONFIELD PKWY | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727504 | ||||||||
| FaxNumber: | 3154798639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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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 | 363L00000X | F331843-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02364863 | 05 | NY | MEDICAID |