MEDICARE: JOEL T SAN NICOLAS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00005032	WA

General Provider Information

NPI Number	:	1003866658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL T SAN NICOLAS PT

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	NINE MILE FALLS
State	:	WA
Zip	:	99026-0549
Country	:	US
Telephone Number	:	509-465-5663
Fax Number	:	509-467-8663

Provider Business Practice Location Address
First Line	:	5928 HIGHWAY 291
Second Line	:
City	:	NINE MILE FALLS
State	:	WA
Zip	:	99026-9525
Country	:	US
Telephone Number	:	509-465-5663
Fax Number	:	509-467-8663

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	07/08/2007

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