Healthcare Provider Details

I. General information

NPI: 1063530434
Provider Name (Legal Business Name): AMIR K. NICKNAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 W BROOKS AVE SUITE A
NORTH LAS VEGAS NV
89030-3900
US

IV. Provider business mailing address

5080 SPECTRUM DR SUITE 1200 WEST
ADDISON TX
75001-4648
US

V. Phone/Fax

Practice location:
  • Phone: 615-778-4066
  • Fax: 615-778-9114
Mailing address:
  • Phone: 972-364-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number11368
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: