Provider Demographics
NPI:1083159727
Name:NICHOLS, TIMOTHY JAMES
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 S XANTHUS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5323
Mailing Address - Country:US
Mailing Address - Phone:619-997-1568
Mailing Address - Fax:
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:619-997-1568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK778225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant