Healthcare Provider Details

I. General information

NPI: 1154621381
Provider Name (Legal Business Name): NICOLAS SNYDER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 W BASELINE RD
PHOENIX AZ
85041-6492
US

IV. Provider business mailing address

4600 S MILL AVE
TEMPE AZ
85282-6757
US

V. Phone/Fax

Practice location:
  • Phone: 480-677-8282
  • Fax: 480-677-8283
Mailing address:
  • Phone: 480-305-2888
  • Fax: 480-305-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4749
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: