Provider Demographics
NPI:1871996116
Name:GAREY, NICOLE ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:GAREY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ROSE
Other - Last Name:KUBART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 825478
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-5478
Mailing Address - Country:US
Mailing Address - Phone:551-999-7050
Mailing Address - Fax:201-392-3571
Practice Address - Street 1:55 MEADOWLANDS PKWY FL 2
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2977
Practice Address - Country:US
Practice Address - Phone:551-999-7050
Practice Address - Fax:201-392-3571
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00436400363A00000X, 363AS0400X
NY018096363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04003641Medicaid
NYA400114572Medicare PIN