Provider Demographics
NPI:1871110692
Name:WAXNER, NICOLE AMANDA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:AMANDA
Last Name:WAXNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BRAMBLE LN
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2317
Mailing Address - Country:US
Mailing Address - Phone:631-813-9031
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1347
Practice Address - Country:US
Practice Address - Phone:516-562-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant