Basic Information
| Provider Information | |||||||||
| NPI: | 1720196884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NAGEL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2187 N VICKEY ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860046121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287145305 | ||||||||
| FaxNumber: | 9287146480 | ||||||||
| Practice Location | |||||||||
| Address1: | 2187 N VICKEY ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860046121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287145305 | ||||||||
| FaxNumber: | 9287146480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
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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 | 2084P0800X | 47618 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 828772 | 05 | AZ | MEDICAID | AN30100092 | 01 | DEA | OTHER |