Provider Demographics
NPI:1831917483
Name:HERIDEEN, NICHOLAS FRANK
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:FRANK
Last Name:HERIDEEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1930
Mailing Address - Country:US
Mailing Address - Phone:330-283-5595
Mailing Address - Fax:
Practice Address - Street 1:3527 UNION RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-5122
Practice Address - Country:US
Practice Address - Phone:716-503-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist