MEDICARE: NICOLA DEACON DPT

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	10280-024	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235330341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLA DEACON DPT

Provider Business Mailing Address
First Line	:	PO BOX 735044
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-5044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9120 W LOOMIS RD STE 100
Second Line	:
City	:	FRANKLIN
State	:	WI
Zip	:	53132-9083
Country	:	US
Telephone Number	:	414-858-1740
Fax Number	:

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

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	10/13/2023

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Directions to “ NICOLA DEACON DPT” Practice Location

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