Individual
ROBERT S NICKOLISEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
601 W RIVERSIDE DR, SUITES 3 AND 4, PARKER, AZ 85344-5119
(602) 377-5900
Mailing address
2485 STROKE DR, LAKE HAVASU CITY, AZ 86406-7622
(602) 377-5900
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
15301
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
250316
—
AZ
Enumeration date
06/03/2006
Last updated
10/27/2010
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