Provider Demographics
NPI:1366420572
Name:WISSINK, NICHOLAS ROBERT (PT, DPT, MATCS,CSCS,)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:WISSINK
Suffix:
Gender:M
Credentials:PT, DPT, MATCS,CSCS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9015 ARBOR ST STE 155
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2072
Mailing Address - Country:US
Mailing Address - Phone:531-213-2666
Mailing Address - Fax:531-213-2386
Practice Address - Street 1:9015 ARBOR ST STE 155
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2072
Practice Address - Country:US
Practice Address - Phone:531-213-2666
Practice Address - Fax:531-213-2386
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36539OtherBCBS
NE10025511900Medicaid
NE10025511800Medicaid
NE099668Medicare PIN
NE099668005Medicare PIN
NE10025511800Medicaid
NEDD5588Medicare PIN