Provider Demographics
NPI:1194399246
Name:NIKOGHOSYAN, GOURGEN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:GOURGEN
Middle Name:
Last Name:NIKOGHOSYAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S BEL AIRE DR
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-1523
Mailing Address - Country:US
Mailing Address - Phone:818-203-6258
Mailing Address - Fax:
Practice Address - Street 1:1000 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2957
Practice Address - Country:US
Practice Address - Phone:818-243-8422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist