Provider Demographics
NPI:1255598900
Name:SYDOW, NICOLE RENEE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:SYDOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3131 E CLARENDON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7069
Mailing Address - Country:US
Mailing Address - Phone:602-253-9168
Mailing Address - Fax:602-251-3126
Practice Address - Street 1:1215 N BEAVER ST
Practice Address - Street 2:SUITE 203
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-773-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.012994208600000X
AZ46018208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery