Provider Demographics
NPI:1649320250
Name:AUSTIN, NICHOLAS A (MSPT, OCS)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:A
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:MSPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13415 FOREST SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-2077
Mailing Address - Country:US
Mailing Address - Phone:502-742-4825
Mailing Address - Fax:502-222-0290
Practice Address - Street 1:214 PARKER DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAGRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-1200
Practice Address - Country:US
Practice Address - Phone:502-222-0280
Practice Address - Fax:502-222-0290
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0041322251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000484221OtherANTHEM PROVIDER ID
KY000000946564OtherBLUE CROSS BLUE SHIELD
KY4132OtherKY STATE LICENSE
KY9514OtherOCS CERTIFICATION
KY7100392180Medicaid
KY7100392180Medicaid
KY0942505Medicare PIN