MEDICARE: MAX WILLARD NICHOLSON 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	PT034019	PA

General Provider Information

NPI Number	:	1801750336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAX WILLARD NICHOLSON III DPT

Provider Business Mailing Address
First Line	:	7 DOCK HILL RD
Second Line	:
City	:	MIDDLEBURG
State	:	PA
Zip	:	17842-8910
Country	:	US
Telephone Number	:	570-837-2123
Fax Number	:	570-837-2185

Provider Business Practice Location Address
First Line	:	2350 E 3RD ST
Second Line	:
City	:	WILLIAMSPORT
State	:	PA
Zip	:	17701-4088
Country	:	US
Telephone Number	:	570-360-5915
Fax Number	:	570-560-6501

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

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	02/05/2026

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