Provider Demographics
NPI:1902416241
Name:BRUNELLE-TRAN, NIKOLA DO (PT)
Entity Type:Individual
Prefix:
First Name:NIKOLA DO
Middle Name:
Last Name:BRUNELLE-TRAN
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 1:7414 E GRAND AVE APT 738
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-4253
Mailing Address - Country:US
Mailing Address - Phone:214-609-4929
Mailing Address - Fax:
Practice Address - Street 1:7414 E GRAND AVE APT 738
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-4253
Practice Address - Country:US
Practice Address - Phone:214-609-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1307269225100000X
HIPT-4929225100000X
TN13012225100000X
CA295213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist