Provider Demographics
NPI:1114480217
Name:NISSEN, TIMOTHY EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:NISSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4019 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-2097
Mailing Address - Country:US
Mailing Address - Phone:501-993-3373
Mailing Address - Fax:
Practice Address - Street 1:ARKANSAS CHILDREN'S HOSPITAL
Practice Address - Street 2:1 CHILDREN'S WAY, SLOT ACH 512-19A
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202
Practice Address - Country:US
Practice Address - Phone:501-364-1874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program