Provider Demographics
NPI:1841513694
Name:DESHANE, NICHOLAS SCOTT (ATC, CSCS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:SCOTT
Last Name:DESHANE
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3979 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2001
Mailing Address - Country:US
Mailing Address - Phone:209-404-6353
Mailing Address - Fax:
Practice Address - Street 1:520420. ATTN SMART CLINIC
Practice Address - Street 2:SOI WEST, CAMP PENDLETON
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-7029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer