Provider Demographics
NPI:1083238125
Name:RODRIGUEZ, NICHOLAS (PTA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 WILSON BLVD APT 712
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-3207
Mailing Address - Country:US
Mailing Address - Phone:434-989-1260
Mailing Address - Fax:
Practice Address - Street 1:7116 FORT HUNT RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307-1900
Practice Address - Country:US
Practice Address - Phone:434-989-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604810208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation