Provider Demographics
NPI:1407273899
Name:RUST, NICHOLAS (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RUST
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:PO BOX 310754
Mailing Address - Street 2:DEPT 4101
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-0754
Mailing Address - Country:US
Mailing Address - Phone:561-255-3131
Mailing Address - Fax:561-244-2591
Practice Address - Street 1:4700 N CONGRESS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3282
Practice Address - Country:US
Practice Address - Phone:561-255-3131
Practice Address - Fax:561-246-3715
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT28885OtherFLORIDA LICENSE
FL010828900Medicaid
FLPT28885OtherFLORIDA LICENSE