Provider Demographics
NPI:1811918345
Name:MCDERMOTT, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:MCDERMOTT
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 1:4045 HEMPSTEAD TPKE FL 3
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5611
Mailing Address - Country:US
Mailing Address - Phone:516-731-7770
Mailing Address - Fax:516-541-1721
Practice Address - Street 1:4045 HEMPSTEAD TPKE FL 3
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5611
Practice Address - Country:US
Practice Address - Phone:516-731-7770
Practice Address - Fax:516-541-1721
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00180363AM0700X
NY008886-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
5F5611Medicare UPIN