Provider Demographics
NPI:1093056103
Name:SMITH, NICHOLAS MICHAEL (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MEYER RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1954
Mailing Address - Country:US
Mailing Address - Phone:716-677-4022
Mailing Address - Fax:
Practice Address - Street 1:425 MEYER RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1954
Practice Address - Country:US
Practice Address - Phone:716-677-4022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00118072255A2300X
NY035839261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy