Healthcare Provider Details

I. General information

NPI: 1689595779
Provider Name (Legal Business Name): NICASIO MIGUEL NANGO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NICASIO MIGUEL WAITE NANGO

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SOUTHERN AVE STE 2046
MESA AZ
85206-6216
US

IV. Provider business mailing address

3707 E SOUTHERN AVE STE 2046
MESA AZ
85206-6216
US

V. Phone/Fax

Practice location:
  • Phone: 480-788-8388
  • Fax:
Mailing address:
  • Phone: 480-433-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: