Provider Demographics
NPI:1942004957
Name:GOSPODINOV, NIKOLAY ANTONOV (RMA)
Entity type:Individual
Prefix:
First Name:NIKOLAY
Middle Name:ANTONOV
Last Name:GOSPODINOV
Suffix:
Gender:M
Credentials:RMA
Other - Prefix:
Other - First Name:IRENA
Other - Middle Name:
Other - Last Name:GOSPODINOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RMA
Mailing Address - Street 1:21021 N 56TH ST APT 3091
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-5609
Mailing Address - Country:US
Mailing Address - Phone:602-377-1064
Mailing Address - Fax:
Practice Address - Street 1:5520 W CHANDLER BLVD STE 3
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3693
Practice Address - Country:US
Practice Address - Phone:602-362-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3041275376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3041275OtherRMA LICENSE