Basic Information
| Provider Information | |||||||||
| NPI: | 1134137458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASQUEZ | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2140 W MARLIN DR | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852866787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036453926 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1955 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807283000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 33930 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00033438 | 01 | AZ | RR MEDICARE | OTHER | 544602 | 05 | AZ | MEDICAID |