Provider Demographics
NPI:1528501392
Name:ANDERSEN, NICHOLAS (RRT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9730 W MOSSYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5392
Mailing Address - Country:US
Mailing Address - Phone:208-954-7433
Mailing Address - Fax:
Practice Address - Street 1:9730 W MOSSYWOOD DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5392
Practice Address - Country:US
Practice Address - Phone:208-954-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLRT-1601227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered