MEDICARE: MR. BRIAN NICHOLSON 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	PT12720	FL

General Provider Information

NPI Number	:	1508477340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN NICHOLSON PT

Provider Business Mailing Address
First Line	:	529 SW GRANDVIEW ST
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6614
Country	:	US
Telephone Number	:	727-992-1978
Fax Number	:

Provider Business Practice Location Address
First Line	:	8100 NW 27TH BLVD APT D116
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-8613
Country	:	US
Telephone Number	:	352-792-6464
Fax Number	:

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

Provider Enumeration Date	:	08/14/2020
Last Update Date	:	08/14/2020

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