Provider Demographics
NPI:1487692125
Name:NICKOLISEN, ROBERT S (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:NICKOLISEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 STROKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7622
Mailing Address - Country:US
Mailing Address - Phone:602-377-5900
Mailing Address - Fax:
Practice Address - Street 1:601 W RIVERSIDE DR
Practice Address - Street 2:SUITES 3 AND 4
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5119
Practice Address - Country:US
Practice Address - Phone:602-377-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15301174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ250316Medicaid
AZ340012840Medicare PIN
AZ250316Medicaid
AZZWMBDTO1Medicare PIN