MEDICARE: NICKOLAS S JOHANNSEN

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1598027666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKOLAS S JOHANNSEN

Provider Business Mailing Address
First Line	:	4015 E BELL RD
Second Line	:	STE 130
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2243
Country	:	US
Telephone Number	:	602-354-7181
Fax Number	:

Provider Business Practice Location Address
First Line	:	4015 E BELL RD
Second Line	:	STE 130
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2243
Country	:	US
Telephone Number	:	602-354-7181
Fax Number	:

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

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	06/13/2012

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