Provider Demographics
NPI:1891929402
Name:NICHOLAS, FEDERICO (PTA20728)
Entity Type:Individual
Prefix:MR
First Name:FEDERICO
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:PTA20728
Other - Prefix:MR
Other - First Name:FEDERICO
Other - Middle Name:
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA20728
Mailing Address - Street 1:1441 FORTUNE RD, #256
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743
Mailing Address - Country:US
Mailing Address - Phone:352-787-3188
Mailing Address - Fax:877-399-5578
Practice Address - Street 1:1441 FORTUNE RD, #256
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743
Practice Address - Country:US
Practice Address - Phone:352-787-3188
Practice Address - Fax:877-399-5578
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20728225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106898OtherMEDICARE ID