Provider Demographics
NPI:1023667227
Name:MUNRO, NICHOLAS JOSEPH (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:MUNRO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 POLK ST APT 13
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1357
Mailing Address - Country:US
Mailing Address - Phone:862-268-4184
Mailing Address - Fax:
Practice Address - Street 1:6620 FLY RD STE 102
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-4281
Practice Address - Country:US
Practice Address - Phone:315-399-4770
Practice Address - Fax:315-399-4771
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044617-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist