Provider Demographics
NPI:1487853099
Name:NORDTVEDT, NICHOLAS CHRISTIAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CHRISTIAN
Last Name:NORDTVEDT
Suffix:
Gender:M
Credentials:PT, 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 1004
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:TN
Mailing Address - Zip Code:38358-1004
Mailing Address - Country:US
Mailing Address - Phone:731-613-2214
Mailing Address - Fax:731-613-2215
Practice Address - Street 1:5 N LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-2548
Practice Address - Country:US
Practice Address - Phone:731-772-2220
Practice Address - Fax:731-772-2223
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN183838OtherBLUE CROSS BLUE SHIELD
TN446538Medicare PIN