Healthcare Provider Details

I. General information

NPI: 1508419219
Provider Name (Legal Business Name): COREY PHILLIPS NICKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 08/31/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP, JBSA LACKLAND AFB
SAN ANTONIO TX
78236
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP, JBSA LACKLAND AFB
SAN ANTONIO TX
78236
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-5034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1322584
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: