Provider Demographics
NPI:1386839850
Name:MADISON, NICHOLAS C (FNP)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:C
Last Name:MADISON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 EAST GARY WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042
Mailing Address - Country:US
Mailing Address - Phone:602-296-5012
Mailing Address - Fax:
Practice Address - Street 1:1201 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3917
Practice Address - Country:US
Practice Address - Phone:602-344-6655
Practice Address - Fax:602-344-6658
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ088121363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR168395Medicaid
ORR103163OtherMEDICARE PART B
OR168395Medicaid
381846Medicare Oscar/Certification