Provider Demographics
NPI:1679728729
Name:CAMPAGNOLA, NICHOLAS J (PT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:CAMPAGNOLA
Suffix:
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 1:36 NORTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1742
Mailing Address - Country:US
Mailing Address - Phone:516-996-4783
Mailing Address - Fax:516-676-8666
Practice Address - Street 1:36 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-1742
Practice Address - Country:US
Practice Address - Phone:516-996-4783
Practice Address - Fax:516-676-8666
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005639OtherLICENSE #