Provider Demographics
NPI:1730785650
Name:NICHOLAS, SAMUEL MARTIN (DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MARTIN
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-0578
Mailing Address - Country:US
Mailing Address - Phone:503-489-1174
Mailing Address - Fax:
Practice Address - Street 1:1630 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4156
Practice Address - Country:US
Practice Address - Phone:503-607-0047
Practice Address - Fax:503-607-0051
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP0003840T225100000X
OR63810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist