Provider Demographics
NPI:1538436258
Name:BOHANAN, NICHOLAS LEE (ATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:LEE
Last Name:BOHANAN
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 1:2708 MARTIN DR
Mailing Address - Street 2:APT 3065
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5044
Mailing Address - Country:US
Mailing Address - Phone:316-648-8525
Mailing Address - Fax:
Practice Address - Street 1:621 SIX FLAGS DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-6305
Practice Address - Country:US
Practice Address - Phone:817-385-8285
Practice Address - Fax:817-385-8261
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT47332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer