Provider Demographics
NPI:1699957332
Name:WESTERN UROLOGICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:WESTERN UROLOGICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:NICKOLISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-377-5900
Mailing Address - Street 1:2485 STROKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7622
Mailing Address - Country:US
Mailing Address - Phone:602-377-5900
Mailing Address - Fax:
Practice Address - Street 1:601 W RIVERSIDE DR
Practice Address - Street 2:SUITES 3 AND 4
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5119
Practice Address - Country:US
Practice Address - Phone:602-377-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15301174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCD4774Medicare PIN
AZZWMBDTMedicare PIN