Provider Demographics
NPI:1194521575
Name:NICOLAS, GERARDO (DPT)
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39530 MEDINA CT
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4514
Mailing Address - Country:US
Mailing Address - Phone:530-965-2772
Mailing Address - Fax:
Practice Address - Street 1:27701 SCOTT RD STE D108
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-9417
Practice Address - Country:US
Practice Address - Phone:530-965-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA307658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist