Provider Demographics
NPI:1972797173
Name:ZASTROW, NICOLAS JAMES (PA)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:JAMES
Last Name:ZASTROW
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:14520 W GRANITE VALLEY DR
Practice Address - Street 2:SUITE 210
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5855
Practice Address - Country:US
Practice Address - Phone:623-537-5600
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3658363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5550830007OtherMEDICARE NSC DV
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830001OtherMEDICARE NSC SCW
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZ5550830010OtherMEDICARE NSC GILBERT
AZZ102176Medicare PIN