Provider Demographics
NPI:1215265426
Name:PUTZAR-DAVIS, NIKI MARIE (NP)
Entity type:Individual
Prefix:
First Name:NIKI
Middle Name:MARIE
Last Name:PUTZAR-DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 E PARADISE FALLS DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6687
Mailing Address - Country:US
Mailing Address - Phone:520-290-5888
Mailing Address - Fax:520-290-5551
Practice Address - Street 1:3945 E PARADISE FALLS DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6687
Practice Address - Country:US
Practice Address - Phone:520-290-5888
Practice Address - Fax:520-290-5551
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-28
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3508363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ503727Medicaid
AZZ136325Medicare PIN