Healthcare Provider Details

I. General information

NPI: 1467248831
Provider Name (Legal Business Name): MR. MICHAEL ANDREW NICHOLAS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

300 POMPTON RD
WAYNE NJ
07470-2705
US

IV. Provider business mailing address

13 SYLVAN WAY
WEST MILFORD NJ
07480-1328
US

V. Phone/Fax

Practice location:
  • Phone: 973-720-2362
  • Fax:
Mailing address:
  • Phone: 973-902-5277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: