Provider Demographics
NPI:1073741096
Name:MATYSIK, NICOLE DANA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DANA
Last Name:MATYSIK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:DANA
Other - Last Name:DEMKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:300 COURTRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2526
Mailing Address - Country:US
Mailing Address - Phone:570-819-4225
Mailing Address - Fax:570-819-4266
Practice Address - Street 1:300 COURTRIGHT ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2526
Practice Address - Country:US
Practice Address - Phone:570-819-4225
Practice Address - Fax:570-819-4266
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1002154225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant