Provider Demographics
NPI:1104851609
Name:NASSAR, NICOLAS (MD)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:
Last Name:NASSAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 HOGAN DR
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-7040
Mailing Address - Country:US
Mailing Address - Phone:909-886-1600
Mailing Address - Fax:909-866-7788
Practice Address - Street 1:406 E VANDERBILT WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3552
Practice Address - Country:US
Practice Address - Phone:909-886-1600
Practice Address - Fax:909-866-7788
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76218207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A762180Medicaid
CA00A762180Medicaid
CA00A732183Medicare ID - Type Unspecified