Healthcare Provider Details

I. General information

NPI: 1063128031
Provider Name (Legal Business Name): NICOLAS TEJADA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 NE 2ND AVE APT 412
MIAMI FL
33132-2908
US

IV. Provider business mailing address

1489 W PALMETTO PARK RD STE 410-X
BOCA RATON FL
33486-3325
US

V. Phone/Fax

Practice location:
  • Phone: 954-609-0978
  • Fax:
Mailing address:
  • Phone: 954-609-0978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number39217
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: