Provider Demographics
NPI:1689278533
Name:PITUK, NICHOLAS PAUL (MS, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:PAUL
Last Name:PITUK
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 CANOSA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-2827
Mailing Address - Country:US
Mailing Address - Phone:703-405-9106
Mailing Address - Fax:
Practice Address - Street 1:6425 S JONES BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3303
Practice Address - Country:US
Practice Address - Phone:703-405-9106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05061902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty