Healthcare Provider Details

I. General information

NPI: 1457035487
Provider Name (Legal Business Name): ROBERT J NICKERSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4362 CASCADE RD SE
GRAND RAPIDS MI
49546-3600
US

IV. Provider business mailing address

4161 MIRAMAR AVE NE
GRAND RAPIDS MI
49525-1525
US

V. Phone/Fax

Practice location:
  • Phone: 616-465-6800
  • Fax:
Mailing address:
  • Phone: 616-706-8415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502006371
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: