1710376165 NPI number — MR. NICHOLAS JOHN CASEY RODRIGUEZ AG-ACNP

Table of content: MR. NICHOLAS JOHN CASEY RODRIGUEZ AG-ACNP (NPI 1710376165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710376165 NPI number — MR. NICHOLAS JOHN CASEY RODRIGUEZ AG-ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ
Provider First Name:
NICHOLAS
Provider Middle Name:
JOHN CASEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AG-ACNP
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:
1710376165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776084
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-273-7700
Provider Business Mailing Address Fax Number:
479-273-7753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 S HORSEBARN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72758-8184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-273-7700
Provider Business Practice Location Address Fax Number:
479-273-7753
Provider Enumeration Date:
01/22/2015

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: 363LA2100X , with the licence number:  ATP-000747 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 2020018088 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 394391ZMTF . This is a "PROVIDER TRANSACTION ACCESS NUMBER (PTAN)" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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