Provider Demographics
NPI:1659501302
Name:A NICKNAM PC
Entity type:Organization
Organization Name:A NICKNAM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:K
Authorized Official - Last Name:NICKNAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-733-6622
Mailing Address - Street 1:PO BOX 34717
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-4717
Mailing Address - Country:US
Mailing Address - Phone:702-733-6622
Mailing Address - Fax:702-382-6622
Practice Address - Street 1:1712 BEARDEN DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4107
Practice Address - Country:US
Practice Address - Phone:702-733-6622
Practice Address - Fax:702-382-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCP615AOtherMEDICARE PTAN
NV1659501302Medicaid