Provider Demographics
NPI:1710376165
Name:RODRIGUEZ, NICHOLAS JOHN CASEY (AG-ACNP)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:JOHN CASEY
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 CLAY EDWARDS DR STE 625
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3278
Mailing Address - Country:US
Mailing Address - Phone:816-455-3990
Mailing Address - Fax:816-455-5351
Practice Address - Street 1:2790 CLAY EDWARDS DR STE 625
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3278
Practice Address - Country:US
Practice Address - Phone:816-455-3990
Practice Address - Fax:816-455-5351
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARATP-000747363LA2100X
MO2020018088363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR394391ZMTFOtherPROVIDER TRANSACTION ACCESS NUMBER (PTAN)