Provider Demographics
NPI:1477039402
Name:NICOL, GARRETT WAYNE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:WAYNE
Last Name:NICOL
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W DOUGLAS AVE STE 1040
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3017
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:7201 E 147TH ST STE 120
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030
Practice Address - Country:US
Practice Address - Phone:816-425-3580
Practice Address - Fax:816-425-3641
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-05883225100000X
MO2018025002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist