Healthcare Provider Details

I. General information

NPI: 1760988224
Provider Name (Legal Business Name): DUSTIN DUANE NICKERSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 N 3RD ST
PHOENIX AZ
85004-1102
US

IV. Provider business mailing address

2149 E WARNER RD STE 102
TEMPE AZ
85284-3495
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-6100
  • Fax: 480-610-6189
Mailing address:
  • Phone: 480-610-6100
  • Fax: 480-610-6189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP11349
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: