Provider Demographics
NPI:1174813729
Name:NISSEN, GREGORY KENT
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:KENT
Last Name:NISSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 S ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6565
Mailing Address - Country:US
Mailing Address - Phone:605-306-6100
Mailing Address - Fax:605-306-6500
Practice Address - Street 1:3801 S ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6565
Practice Address - Country:US
Practice Address - Phone:605-306-6140
Practice Address - Fax:605-306-6500
Is Sole Proprietor?:No
Enumeration Date:2011-04-17
Last Update Date:2022-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD109152086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery