Provider Demographics
NPI:1215212832
Name:DIDAS, NICOLE M (DPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:DIDAS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 JOHN ROEMMELT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-8301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 JOHN ROEMMELT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8301
Practice Address - Country:US
Practice Address - Phone:607-796-5934
Practice Address - Fax:607-796-4922
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027367-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist