Provider Demographics
NPI:1467942318
Name:EISENMENGER, NICHOLAS CHRISTIAN (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CHRISTIAN
Last Name:EISENMENGER
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 1:650 N SHORELINE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6677
Mailing Address - Country:US
Mailing Address - Phone:907-376-6363
Mailing Address - Fax:907-376-6366
Practice Address - Street 1:650 N SHORELINE DR STE 101
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6677
Practice Address - Country:US
Practice Address - Phone:907-376-6363
Practice Address - Fax:907-376-6366
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
AK146656225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty