Provider Demographics
NPI:1447308457
Name:NIKOLOS, GREGORY (PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:NIKOLOS
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 1:2725 NE 8TH AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33334-2652
Mailing Address - Country:US
Mailing Address - Phone:917-676-8328
Mailing Address - Fax:
Practice Address - Street 1:3650 NW 82ND AVE STE 201
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6662
Practice Address - Country:US
Practice Address - Phone:305-537-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009749-1363AS0400X
FL9106591363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical