Provider Demographics
NPI:1639684699
Name:NICHOLLS, JOHNATHAN TYLER (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:TYLER
Last Name:NICHOLLS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9424 W EATON RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4274
Mailing Address - Country:US
Mailing Address - Phone:801-808-2672
Mailing Address - Fax:
Practice Address - Street 1:8424 E SHEA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-256-1520
Practice Address - Fax:480-478-6628
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6566569-3102163W00000X
AZ1494367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ390207Medicaid