Provider Demographics
NPI:1376093492
Name:HARTWIGSEN, NICHOLAS (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:HARTWIGSEN
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 ALFA CT APT 2B
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-2981
Mailing Address - Country:US
Mailing Address - Phone:952-221-4744
Mailing Address - Fax:
Practice Address - Street 1:1903 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5200
Practice Address - Country:US
Practice Address - Phone:952-221-4744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010015702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer