Healthcare Provider Details

I. General information

NPI: 1003217324
Provider Name (Legal Business Name): NICHOLAS MIANO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 WINTERBERRY RD
SAUNDERSTOWN RI
02874-2438
US

IV. Provider business mailing address

129 WINTERBERRY RD
SAUNDERSTOWN RI
02874-2438
US

V. Phone/Fax

Practice location:
  • Phone: 401-932-1603
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA00993
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: