Provider Demographics
NPI:1891059549
Name:WITTMAN, NICHOLAS MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:WITTMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S KIRKWOOD RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-7254
Mailing Address - Country:US
Mailing Address - Phone:314-966-6393
Mailing Address - Fax:
Practice Address - Street 1:1001 S KIRKWOOD RD
Practice Address - Street 2:SUITE 160
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-7254
Practice Address - Country:US
Practice Address - Phone:314-966-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor