Provider Demographics
NPI:1891573507
Name:HERNANDEZ, NICOLAS JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:JOSEPH
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-3800
Mailing Address - Country:US
Mailing Address - Phone:631-704-8873
Mailing Address - Fax:
Practice Address - Street 1:711 ROUTE 10 E STE 200
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2030
Practice Address - Country:US
Practice Address - Phone:973-584-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050771-01225100000X
NCP22610225100000X
TX1382367225100000X
NJ40QA02245500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist