Provider Demographics
NPI:1619497997
Name:CLAISE, NICKOLAS WAYNE (DPT)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:WAYNE
Last Name:CLAISE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-796-4698
Mailing Address - Fax:270-782-3274
Practice Address - Street 1:1110 WILKINSON TRCE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-418-3324
Practice Address - Fax:270-418-3326
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYT16109225100000X
KY007135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist