Basic Information
| Provider Information | |||||||||
| NPI: | 1811072002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELLICIARI | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | RPAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | VC2, SUITE 260 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | 2123056792 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 WEST 168TH STREET | ||||||||
| Address2: | VC2 SUITE 260 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123052995 | ||||||||
| FaxNumber: | 2123056792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 02/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 010705 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 00695941 | 05 | NY | MEDICAID |