Provider Demographics
NPI:1700280666
Name:OBRECHT, NICOLE DANIELLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DANIELLE
Last Name:OBRECHT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DANIELLE
Other - Last Name:CORTESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1555 LONG POND RD
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4122
Mailing Address - Country:US
Mailing Address - Phone:585-723-7870
Mailing Address - Fax:585-723-7871
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7870
Practice Address - Fax:585-723-7871
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018183363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400182524/GRP70008AMedicare PIN
NYJ400182522/GRPBA0017Medicare PIN