Provider Demographics
NPI:1073915864
Name:ANDERSON, NICOLAS CHACE
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:CHACE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 HEBER AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5087
Mailing Address - Country:US
Mailing Address - Phone:435-757-6142
Mailing Address - Fax:
Practice Address - Street 1:7274 WARDLEIGH RD BAY J
Practice Address - Street 2:
Practice Address - City:HILL AIR FORCE BASE
Practice Address - State:UT
Practice Address - Zip Code:84056-5137
Practice Address - Country:US
Practice Address - Phone:435-757-6142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT7502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer