MEDICARE: MR. MARCUS NIELSON PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN168434	AZ
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	301764	AZ

General Provider Information

NPI Number	:	1376257170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARCUS NIELSON PMHNP-BC

Provider Business Mailing Address
First Line	:	647 N ROBSON
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-5040
Country	:	US
Telephone Number	:	480-710-3627
Fax Number	:

Provider Business Practice Location Address
First Line	:	2355 E CAMELBACK RD STE 625
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-3458
Country	:	US
Telephone Number	:	480-581-8536
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2023
Last Update Date	:	09/08/2024

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