Provider Demographics
NPI:1467972505
Name:GAFFNEY, NICK (PTA)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:GAFFNEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 CHELSEA CT
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-8915
Mailing Address - Country:US
Mailing Address - Phone:920-850-2561
Mailing Address - Fax:
Practice Address - Street 1:104 FAKES CT
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2699
Practice Address - Country:US
Practice Address - Phone:920-356-9818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant