Provider Demographics
NPI:1326800509
Name:NICKEL, RANDALL (PT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:NICKEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 NAGAWICKA SHORES DR
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-8817
Mailing Address - Country:US
Mailing Address - Phone:262-470-3279
Mailing Address - Fax:
Practice Address - Street 1:2900 GOLF RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5449
Practice Address - Country:US
Practice Address - Phone:262-928-7356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic