Basic Information
| Provider Information | |||||||||
| NPI: | 1730785650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 578 | ||||||||
| Address2: | |||||||||
| City: | TROUTDALE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970600578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034891174 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1630 BEAVERCREEK RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036070047 | ||||||||
| FaxNumber: | 5036070051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2020 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | CP0003840T | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 63810 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.