Provider Demographics
NPI:1679679088
Name:NICHOLS, BRIAN DAVID (MPT ATC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9652 W STATE STREET
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5858
Mailing Address - Country:US
Mailing Address - Phone:208-286-0766
Mailing Address - Fax:208-286-0768
Practice Address - Street 1:9652 W STATE STREET
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5858
Practice Address - Country:US
Practice Address - Phone:208-286-0766
Practice Address - Fax:208-286-0768
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1136225100000X
IDRPT1136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010147595OtherREGENCE BLUE SHIELD
ID806941900Medicaid
IDTA229OtherBLUE CROSS #
ID1655436Medicare PIN