Provider Demographics
NPI:1184811804
Name:NICOARA, BRUCE MICHAEL (DPT)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MICHAEL
Last Name:NICOARA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 441146
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30160-9522
Mailing Address - Country:US
Mailing Address - Phone:678-403-3632
Mailing Address - Fax:678-567-6737
Practice Address - Street 1:11808 KINGSTON PIKE
Practice Address - Street 2:SUITE 185
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-3803
Practice Address - Country:US
Practice Address - Phone:865-675-2820
Practice Address - Fax:865-675-2821
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79152251X0800X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist