Provider Demographics
NPI:1619148087
Name:NIKICIUK, BARTOSZ MICHAL (PT)
Entity Type:Individual
Prefix:
First Name:BARTOSZ
Middle Name:MICHAL
Last Name:NIKICIUK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5047 SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7607
Mailing Address - Country:US
Mailing Address - Phone:704-780-1558
Mailing Address - Fax:
Practice Address - Street 1:11218 PROVIDENCE RD W STE C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4787
Practice Address - Country:US
Practice Address - Phone:704-780-1558
Practice Address - Fax:704-780-1108
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026282174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02567600Medicaid