Provider Demographics
NPI:1619357696
Name:PETERSON, NICHOLAS L (PT, DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 COUNTY ROAD 335 UNIT B
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:CO
Mailing Address - Zip Code:81647-9691
Mailing Address - Country:US
Mailing Address - Phone:401-213-9842
Mailing Address - Fax:
Practice Address - Street 1:6420 COUNTY ROAD 335 UNIT B
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:CO
Practice Address - Zip Code:81647-9691
Practice Address - Country:US
Practice Address - Phone:401-213-9842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17088225100000X
SC7961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH3025Medicaid
SCTH3025Medicaid