Provider Demographics
NPI:1578066437
Name:GORANSON, NICHOLAS A (COTA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:GORANSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 BISMARCK AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-5616
Mailing Address - Country:US
Mailing Address - Phone:920-203-2741
Mailing Address - Fax:
Practice Address - Street 1:1700 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1230
Practice Address - Country:US
Practice Address - Phone:920-739-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5256-27225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist