Provider Demographics
NPI:1578010294
Name:NICOLAI, MATTHEW ALAN
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALAN
Last Name:NICOLAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 NOBLET RD
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-8713
Mailing Address - Country:US
Mailing Address - Phone:810-341-3811
Mailing Address - Fax:
Practice Address - Street 1:437 N 1ST ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3205
Practice Address - Country:US
Practice Address - Phone:810-341-3811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-11
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24122255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer