Provider Demographics
NPI:1497188197
Name:NICHOLSON, ALEXANDER JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JOSEPH
Last Name:NICHOLSON
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 1:4140 E BASELINE RD STE 112
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4413
Mailing Address - Country:US
Mailing Address - Phone:602-734-0252
Mailing Address - Fax:
Practice Address - Street 1:4140 E BASELINE RD STE 112
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4413
Practice Address - Country:US
Practice Address - Phone:602-734-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR77212390200000X
AZ66165207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program