MEDICARE: TAMARA A NICKSIC 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	05002433A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05002433A	OTHER	IN	LPT

General Provider Information

NPI Number	:	1649479544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA A NICKSIC PT

Provider Business Mailing Address
First Line	:	2203 WYNNEWOOD DR
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46385-2828
Country	:	US
Telephone Number	:	219-789-5865
Fax Number	:

Provider Business Practice Location Address
First Line	:	8259 WICKER AVE
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8878
Country	:	US
Telephone Number	:	219-365-6560
Fax Number	:	219-365-6561

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

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	11/08/2018

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