Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 60360553 | WA |
Y | 2251G0304X | Physical Therapist - Geriatrics | 60380553 | WA |
NPI | 1194346502 |
---|---|
Provider Name | Charles Nichols III |
First Address | Spokane, WA 99205-6224 |
Second Address | Spokane, WA 99205-6224 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2020 |
Last Update Date | 04/05/2020 |