Provider Demographics
NPI:1861432668
Name:NICOLETTI, JEFF (PA)
Entity type:Individual
Prefix:MR
First Name:JEFF
Middle Name:
Last Name:NICOLETTI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HEALTHCARE DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005
Mailing Address - Country:US
Mailing Address - Phone:207-282-9880
Mailing Address - Fax:207-282-9180
Practice Address - Street 1:10 WELLSPRING ROAD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005
Practice Address - Country:US
Practice Address - Phone:207-283-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME061436OtherANTHEM
MEQ47449Medicare UPIN
AP2444Medicare ID - Type Unspecified