MEDICARE: MR. EVERETT NICOLAI III 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	00010235	WA
2	225100000X	Physical Therapist	64923	OR

General Provider Information

NPI Number	:	1639263718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EVERETT NICOLAI III DPT

Provider Business Mailing Address
First Line	:	9735 SW SHADY LN STE 203
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-5481
Country	:	US
Telephone Number	:	503-223-1856
Fax Number	:	503-223-1765

Provider Business Practice Location Address
First Line	:	9735 SW SHADY LN STE 203
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-5481
Country	:	US
Telephone Number	:	503-223-1856
Fax Number	:	503-223-1765

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/31/2023

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