Provider Demographics
NPI:1497509178
Name:NICASIO, VANNA MARGARITA (PA)
Entity type:Individual
Prefix:
First Name:VANNA
Middle Name:MARGARITA
Last Name:NICASIO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 AUDUBON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4677
Mailing Address - Country:US
Mailing Address - Phone:646-981-7755
Mailing Address - Fax:
Practice Address - Street 1:461 AUDUBON AVE APT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-4677
Practice Address - Country:US
Practice Address - Phone:646-981-7755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2107-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical