Provider Demographics
NPI:1003587270
Name:DOLEZAL, NICHOLAS SCOTT (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:SCOTT
Last Name:DOLEZAL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 HWAY 95 STE 61
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7896
Mailing Address - Country:US
Mailing Address - Phone:928-440-6880
Mailing Address - Fax:
Practice Address - Street 1:3003 HWAY 95 STE 61
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7896
Practice Address - Country:US
Practice Address - Phone:928-440-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-32019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLPT-32019OtherARIZONA STATE LICENSE