Provider Demographics
NPI:1720661473
Name:SANDERS, NICHOLAS B (PTA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:B
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 SUSANNAH ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1748
Mailing Address - Country:US
Mailing Address - Phone:423-282-9011
Mailing Address - Fax:423-282-0035
Practice Address - Street 1:875 LARRY NEIL WAY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6368
Practice Address - Country:US
Practice Address - Phone:423-282-9011
Practice Address - Fax:423-282-0035
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7310225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant