Provider Demographics
NPI:1417233784
Name:NAKAGAMA, NICHOLAS (ATC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:NAKAGAMA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 E ELLEN LN
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-2304
Mailing Address - Country:US
Mailing Address - Phone:801-541-2130
Mailing Address - Fax:
Practice Address - Street 1:280 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6136
Practice Address - Country:US
Practice Address - Phone:801-298-2495
Practice Address - Fax:801-298-2801
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7786912-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer