Basic Information
| Provider Information | |||||||||
| NPI: | 1992089536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUGUMARAN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHEDELER | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17667 N 97TH ST | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852552634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803710114 | ||||||||
| FaxNumber: | 4803710114 | ||||||||
| Practice Location | |||||||||
| Address1: | 7332 E BUTHERUS DR HNGR 1 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852608005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024063000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2011 | ||||||||
| LastUpdateDate: | 07/16/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4991 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 4991 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.