Provider Demographics
NPI:1992769632
Name:NICOLOFF, NICK NICOLAEV (RPA-C)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:NICOLAEV
Last Name:NICOLOFF
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CLAREWOOD DR
Mailing Address - Street 2:APT 4E
Mailing Address - City:HASTINGS ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10706-3652
Mailing Address - Country:US
Mailing Address - Phone:917-388-7644
Mailing Address - Fax:
Practice Address - Street 1:445 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-1780
Practice Address - Country:US
Practice Address - Phone:718-676-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009001-1363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P48238Medicare UPIN
5F757EZ521Medicare PIN