Healthcare Provider Details

I. General information

NPI: 1477817450
Provider Name (Legal Business Name): NICHOLAS PAUL KUCINSKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10230 W HAPPY VALLEY PKWY
PEORIA AZ
85383-4691
US

IV. Provider business mailing address

2500 W UTOPIA RD SUITE 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 623-561-3030
  • Fax: 623-825-5630
Mailing address:
  • Phone: 623-434-6200
  • Fax: 623-434-6164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number006440
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR73472
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: