Provider Demographics
NPI:1881349355
Name:NICHOLSON, JAMES MARK ANTHONY (LMT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MARK ANTHONY
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BRUCKNER BLVD APT 3U
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-4577
Mailing Address - Country:US
Mailing Address - Phone:917-653-5090
Mailing Address - Fax:
Practice Address - Street 1:240 E 56TH ST RM 4W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-3769
Practice Address - Country:US
Practice Address - Phone:917-653-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019126172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist