Provider Demographics
NPI:1578536322
Name:NICHOLS, JOE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:LYNN
Last Name:NICHOLS
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 1:1850 N CENTRAL AVE
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4527
Mailing Address - Country:US
Mailing Address - Phone:602-262-8900
Mailing Address - Fax:602-262-8890
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:SUITE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4527
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:602-262-8890
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18058207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ297079Medicaid
E35668Medicare UPIN
AZ297079Medicaid