Healthcare Provider Details

I. General information

NPI: 1699557736
Provider Name (Legal Business Name): NICHOLAS LAZZARO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 FIVE CITIES DR STE C6
PISMO BEACH CA
93449-3006
US

IV. Provider business mailing address

408 HIGUERA ST STE 200
SAN LUIS OBISPO CA
93401-6135
US

V. Phone/Fax

Practice location:
  • Phone: 805-489-7912
  • Fax: 805-489-9697
Mailing address:
  • Phone: 805-788-0805
  • Fax: 805-788-0845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT307438
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: