1114633815 NPI number — NICHOLAS CONRAD EISEMANN-ASTONE PMHNP

Table of content: NICHOLAS CONRAD EISEMANN-ASTONE PMHNP (NPI 1114633815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114633815 NPI number — NICHOLAS CONRAD EISEMANN-ASTONE PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EISEMANN-ASTONE
Provider First Name:
NICHOLAS
Provider Middle Name:
CONRAD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114633815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7165 E UNIVERSITY DR STE 155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85207-6412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-913-5872
Provider Business Mailing Address Fax Number:
602-848-3105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1642 S PRIEST DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85281-6204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-216-7094
Provider Business Practice Location Address Fax Number:
602-389-3683
Provider Enumeration Date:
01/25/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  226243 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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