NPIMap

Organization Active NPI

A Nicknam PC

  • Family Medicine Physician
  • Las Vegas, NV
National Provider Identifier
1659501302
Registry record updated Dec 31, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
11368 Issued in NV
Legal business name
A NICKNAM PC
Practice address
1712 Bearden Dr
Las Vegas, NV 89106-4107
Phone
(702) 733-6622
Fax
(702) 382-6622
NPI assigned
Jul 15, 2009
Last updated
Dec 31, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 31, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Amir K Nicknam, MDNPI 1063530434
Title
President
Phone
(702) 733-6622

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 11368 NV Primary

Addresses

Primary practice location

1712 Bearden Dr
Las Vegas, NV 89106-4107

Mailing address

PO Box 34717
Las Vegas, NV 89133-4717
Phone (702) 733-6622

Other identifiers 2

IdentifierTypeStateIssuer
CP615AOtherNVMEDICARE PTAN
1659501302MedicaidNV

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100107000171 NV Part B Supplier - Clinic/Group Practice 1052452422 Receives reassigned benefits from 11 practitioners
Practice locations: Las Vegas, NV; North Las Vegas, NV

National Provider Directory

National Provider Directory

Locations

1712 Wellness Way
Las Vegas, NV 89106
Phone (702) 360-5439

1765 Village Center Cir
Las Vegas, NV 89134

4060 N Martin L King Blvd
Ste 101
North Las Vegas, NV 89032
Phone (702) 380-1712

4060 N Martin L King Blvd
Ste 101A
North Las Vegas, NV 89032
Phone (702) 646-5433

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1247616000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1388448000000",
    "number": "1659501302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 34717",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891334717",
            "telephone_number": "702-733-6622",
            "fax_number": "702-382-6622"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1712 BEARDEN DR",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891064107",
            "telephone_number": "702-733-6622",
            "fax_number": "702-382-6622"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "A NICKNAM PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-07-15",
        "last_updated": "2013-12-31",
        "status": "A",
        "authorized_official_last_name": "NICKNAM",
        "authorized_official_first_name": "AMIR",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "702-733-6622",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NV",
            "license": "11368",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "CP615A",
            "state": "NV"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1659501302",
            "state": "NV"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Las Vegas, NV

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 31, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.