Provider Demographics
NPI:1457035487
Name:NICKERSON, ROBERT J (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 MIRAMAR AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1525
Mailing Address - Country:US
Mailing Address - Phone:616-706-8415
Mailing Address - Fax:
Practice Address - Street 1:4362 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3600
Practice Address - Country:US
Practice Address - Phone:616-465-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006371225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant