Provider Demographics
NPI:1720556426
Name:ALBERTSON, NICHOLAS (LAT, ATC)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ALBERTSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 CHESTERFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-4495
Mailing Address - Country:US
Mailing Address - Phone:317-340-7099
Mailing Address - Fax:
Practice Address - Street 1:1100 E 5TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-3462
Practice Address - Country:US
Practice Address - Phone:317-340-7099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22782081S0010X
IN36002316A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine