Healthcare Provider Details

I. General information

NPI: 1548837743
Provider Name (Legal Business Name): CONNOR NICKEL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10721 W INDIAN SCHOOL RD
AVONDALE AZ
85392-5636
US

IV. Provider business mailing address

14287 N 87TH ST STE 220
SCOTTSDALE AZ
85260-3698
US

V. Phone/Fax

Practice location:
  • Phone: 623-772-7748
  • Fax: 623-772-7749
Mailing address:
  • Phone: 602-329-8250
  • Fax: 480-565-1898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: