Basic Information
| Provider Information | |||||||||
| NPI: | 1700148731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISCHMEIER | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | KURT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 3420 S MERCY RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 94-07858 | KS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | ME131765 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 56351 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020494500 | 05 | FL | MEDICAID | 7179580 | 01 | FL | CIGNA | OTHER | JMZY9 | 01 | FL | FL BCBS | OTHER |