Provider Demographics
NPI:1598446437
Name:NICOLDS, KYRIE JAE (PA-C)
Entity type:Individual
Prefix:
First Name:KYRIE
Middle Name:JAE
Last Name:NICOLDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KYRIE
Other - Middle Name:JAE
Other - Last Name:SUTHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26224 N TATUM BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7500
Mailing Address - Country:US
Mailing Address - Phone:480-663-9632
Mailing Address - Fax:480-419-6782
Practice Address - Street 1:26224 N TATUM BLVD STE 15A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7500
Practice Address - Country:US
Practice Address - Phone:486-663-9632
Practice Address - Fax:623-748-1914
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant