Provider Demographics
NPI:1063128031
Name:TEJADA, NICOLAS (PT)
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:TEJADA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 TREE TOPS RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1185
Mailing Address - Country:US
Mailing Address - Phone:954-609-0978
Mailing Address - Fax:
Practice Address - Street 1:3000 SW 148TH AVE STE 115
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4181
Practice Address - Country:US
Practice Address - Phone:954-438-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL39217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist