Provider Demographics
NPI:1073535357
Name:FISSETTE, BRUCE WAYNE (DC, PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:WAYNE
Last Name:FISSETTE
Suffix:
Gender:M
Credentials:DC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 W BAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4516
Mailing Address - Country:US
Mailing Address - Phone:949-673-3154
Mailing Address - Fax:949-723-8348
Practice Address - Street 1:7020 TRASK AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-2622
Practice Address - Country:US
Practice Address - Phone:949-673-3154
Practice Address - Fax:949-723-8348
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26387111N00000X
CARHC147634111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC26387Medicare ID - Type UnspecifiedMEDICARE
CAU82781Medicare UPIN