Provider Demographics
NPI:1053331033
Name:NICHOLSON, ANDREW M (MS, ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S SMYSER RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9394
Mailing Address - Country:US
Mailing Address - Phone:330-465-7048
Mailing Address - Fax:330-345-3800
Practice Address - Street 1:300 S SMYSER RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9394
Practice Address - Country:US
Practice Address - Phone:330-465-7048
Practice Address - Fax:330-345-3800
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 1162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2255A2300XOtherSPECIALIST/TECHNOLOGIST-