Provider Demographics
NPI:1306026687
Name:SHREVE, NICHOLAS EDWARD (PTA)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:SHREVE
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 1:325 4TH ST W
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:298 TRICORN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25053-7148
Practice Address - Country:US
Practice Address - Phone:304-369-1385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001310225200000X
PATEI000859225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant