Provider Demographics
NPI:1386730257
Name:NICHOLSON, JOSEPH A JR (PT)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:NICHOLSON
Suffix:JR
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 1:109 BRIDGE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1222
Mailing Address - Country:US
Mailing Address - Phone:434-793-4711
Mailing Address - Fax:434-797-2514
Practice Address - Street 1:109 BRIDGE ST STE 300
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1222
Practice Address - Country:US
Practice Address - Phone:434-793-4711
Practice Address - Fax:434-797-2514
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1386730257Medicaid
VA2305002703OtherSTATE OF VIRGINIA LICENSE
VA0786860001Medicare NSC
VAC00025Medicare PIN
VA2305002703OtherSTATE OF VIRGINIA LICENSE