Basic Information
| Provider Information | |||||||||
| NPI: | 1760988224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKERSON | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | DUANE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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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 | 163WC0200X | RN | AZ | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 363L00000X | AP11349 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.