Basic Information
| Provider Information | |||||||||
| NPI: | 1992320535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEOVICH | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117574922 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 423 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100105011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126867500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2020 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 025080 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.