MEDICARE: NICHOLAS SMITH

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	PT33869	FL

General Provider Information

NPI Number	:	1760941306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS SMITH

Provider Business Mailing Address
First Line	:	3745 PIAZZA DR APT 201
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-8134
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3745 PIAZZA DR APT 201
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-8134
Country	:	US
Telephone Number	:	910-333-3386
Fax Number	:

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

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	06/11/2019

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Directions to “ NICHOLAS SMITH ” Practice Location

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