Healthcare Provider Details

I. General information

NPI: 1164063384
Provider Name (Legal Business Name): NICHOLAS ANTHONY MULRAIN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 18TH ST NE
WASHINGTON DC
20018-1301
US

IV. Provider business mailing address

6925 GEORGIA AVE NW # 16
WASHINGTON DC
20012-2477
US

V. Phone/Fax

Practice location:
  • Phone: 202-715-7602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA000036
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: