Provider Demographics
NPI:1104448489
Name:RUGGIERO, NICHOLAS (PA-C)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:RUGGIERO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-4420
Mailing Address - Country:US
Mailing Address - Phone:718-619-6124
Mailing Address - Fax:
Practice Address - Street 1:136 BROOK AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4420
Practice Address - Country:US
Practice Address - Phone:718-619-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant