Provider Demographics
NPI:1467828509
Name:PISANO, NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PISANO
Suffix:
Gender:F
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 1:719 N BEERS ST STE 1E
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1523
Mailing Address - Country:US
Mailing Address - Phone:732-739-4414
Mailing Address - Fax:
Practice Address - Street 1:719 N BEERS ST STE 1E
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1523
Practice Address - Country:US
Practice Address - Phone:732-739-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00371100363A00000X
NY019307363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant