Provider Demographics
NPI:1588453930
Name:MARCACCIO, NICCOLO ALEXANDER
Entity type:Individual
Prefix:
First Name:NICCOLO
Middle Name:ALEXANDER
Last Name:MARCACCIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 E CABARRUS ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1912
Mailing Address - Country:US
Mailing Address - Phone:336-326-8037
Mailing Address - Fax:
Practice Address - Street 1:5220 GREENS DAIRY RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-4612
Practice Address - Country:US
Practice Address - Phone:919-781-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-15817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant