Healthcare Provider Details

I. General information

NPI: 1720556426
Provider Name (Legal Business Name): NICHOLAS ALBERTSON LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E 5TH ST
ANDERSON IN
46012-3462
US

IV. Provider business mailing address

1417 CHESTERFIELD AVE
ANDERSON IN
46012-4495
US

V. Phone/Fax

Practice location:
  • Phone: 317-340-7099
  • Fax:
Mailing address:
  • Phone: 317-340-7099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2278
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002316A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: