Provider Demographics
NPI:1306036140
Name:NISA, NUZHAT UN (MD)
Entity Type:Individual
Prefix:
First Name:NUZHAT
Middle Name:UN
Last Name:NISA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SVCS
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-966-5949
Mailing Address - Fax:765-962-6268
Practice Address - Street 1:795 SIM HODGIN PARKWAY
Practice Address - Street 2:RICHMOND FAMILY CARE CENTER
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1928
Practice Address - Country:US
Practice Address - Phone:765-966-5949
Practice Address - Fax:765-962-6268
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067431A207QS1201X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000673201OtherANTHEM
IN200990030Medicaid
IN200990030Medicaid