Provider Demographics
NPI:1174022990
Name:BIBEAU, NICHOLAS RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:BIBEAU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 S WALLRADE LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1494
Mailing Address - Country:US
Mailing Address - Phone:719-338-3168
Mailing Address - Fax:
Practice Address - Street 1:4374 EAST BUTTE AVENUE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132
Practice Address - Country:US
Practice Address - Phone:520-868-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-30635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist