Healthcare Provider Details

I. General information

NPI: 1083159727
Provider Name (Legal Business Name): TIMOTHY JAMES NICHOLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S UTICA AVE
TULSA OK
74104-6520
US

IV. Provider business mailing address

1733 S XANTHUS AVE
TULSA OK
74104-5323
US

V. Phone/Fax

Practice location:
  • Phone: 619-997-1568
  • Fax:
Mailing address:
  • Phone: 619-997-1568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number778
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: