MEDICARE: NICOLAS BRAVO III

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	225X00000X	Occupational Therapist	05701	MD
2	225X00000X	Occupational Therapist	OC014474	PA

General Provider Information

NPI Number	:	1598878852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLAS BRAVO III

Provider Business Mailing Address
First Line	:	300 HOSPITAL RD
Second Line	:
City	:	FORT GORDON
State	:	GA
Zip	:	30905-5950
Country	:	US
Telephone Number	:	706-787-1049
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 HOSPITAL RD
Second Line	:
City	:	FORT GORDON
State	:	GA
Zip	:	30905-5950
Country	:	US
Telephone Number	:	706-787-1049
Fax Number	:

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	05/22/2023

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Directions to “ NICOLAS BRAVO III ” Practice Location

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