Provider Demographics
NPI:1760988224
Name:NICKERSON, DUSTIN DUANE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:DUANE
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 E WARNER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3495
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:480-610-6189
Practice Address - Street 1:2610 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1102
Practice Address - Country:US
Practice Address - Phone:480-610-6100
Practice Address - Fax:480-610-6189
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN163WC0200X
AZAP11349363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty