Provider Demographics
NPI:1639263718
Name:NICOLAI, EVERETT III (DPT)
Entity Type:Individual
Prefix:MR
First Name:EVERETT
Middle Name:
Last Name:NICOLAI
Suffix:III
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 1:9735 SW SHADY LN STE 203
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5481
Mailing Address - Country:US
Mailing Address - Phone:503-223-1856
Mailing Address - Fax:503-223-1765
Practice Address - Street 1:9735 SW SHADY LN STE 203
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5481
Practice Address - Country:US
Practice Address - Phone:503-223-1856
Practice Address - Fax:503-223-1765
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00010235225100000X
OR64923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist