Provider Demographics
NPI:1497264287
Name:ANDERSHOCK, NICHOLAS RHYS (PT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RHYS
Last Name:ANDERSHOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:RHYS
Other - Last Name:ANDERSHOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT, COMT
Mailing Address - Street 1:8522 N 114TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-3450
Mailing Address - Country:US
Mailing Address - Phone:219-707-6439
Mailing Address - Fax:
Practice Address - Street 1:250 N LITCHFIELD RD STE 155
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1367
Practice Address - Country:US
Practice Address - Phone:623-882-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT026436225100000X
AZLPT-30072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1497264287Medicaid