Provider Demographics
NPI:1649846593
Name:ANDERSEN, NICHOLAS WILLIAM (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:WILLIAM
Last Name:ANDERSEN
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 1:9918 E THEIA DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-8494
Mailing Address - Country:US
Mailing Address - Phone:480-242-3395
Mailing Address - Fax:
Practice Address - Street 1:3627 E INDIAN SCHOOL RD STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-5159
Practice Address - Country:US
Practice Address - Phone:419-271-3235
Practice Address - Fax:480-452-1687
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-31768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty