Healthcare Provider Details

I. General information

NPI: 1851812671
Provider Name (Legal Business Name): NICK J JOHNSON I N.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2017
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 N 91ST ST STE A115
SCOTTSDALE AZ
85258-5036
US

IV. Provider business mailing address

3757 E SEXTON ST
GILBERT AZ
85295-7210
US

V. Phone/Fax

Practice location:
  • Phone: 480-322-8577
  • Fax:
Mailing address:
  • Phone: 480-322-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number17-1629
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: