Provider Demographics
NPI:1033495700
Name:BAKOS, NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BAKOS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2812
Mailing Address - Country:US
Mailing Address - Phone:304-599-2515
Mailing Address - Fax:304-285-3738
Practice Address - Street 1:170 LAKEVIEW DR
Practice Address - Street 2:SUITE 2
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-9284
Practice Address - Country:US
Practice Address - Phone:304-594-1545
Practice Address - Fax:304-594-1547
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV000779225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant