Provider Demographics
NPI:1962046367
Name:ANTONIO, NICHOLAS JAMES (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:ANTONIO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 TRUE HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14615-1321
Mailing Address - Country:US
Mailing Address - Phone:585-690-7167
Mailing Address - Fax:
Practice Address - Street 1:95 CANAL LANDING BLVD STE 2-3
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-5111
Practice Address - Country:US
Practice Address - Phone:585-617-0581
Practice Address - Fax:585-617-0438
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-12-17
Deactivation Date:2019-10-30
Deactivation Code:
Reactivation Date:2019-12-17
Provider Licenses
StateLicense IDTaxonomies
NY044497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist