Provider Demographics
NPI:1043279847
Name:NICOLLA, THOMAS CHRISTOPHER JR (PT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:CHRISTOPHER
Last Name:NICOLLA
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-786-1667
Mailing Address - Fax:518-786-1954
Practice Address - Street 1:711 TROY SCHENECTADY RD
Practice Address - Street 2:SUITE 214
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-690-2882
Practice Address - Fax:518-690-2884
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY003627-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01146607Medicaid
NY650021313OtherRR MEDICARE
NY53641BMedicare PIN
NYQ5766QE192Medicare PIN