Provider Demographics
NPI:1306842711
Name:NISSEN, RICK LEE (MD)
Entity Type:Individual
Prefix:MR
First Name:RICK
Middle Name:LEE
Last Name:NISSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8714 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2738
Mailing Address - Country:US
Mailing Address - Phone:952-948-9695
Mailing Address - Fax:952-948-9086
Practice Address - Street 1:8714 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55420-2738
Practice Address - Country:US
Practice Address - Phone:952-948-9695
Practice Address - Fax:952-948-9086
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30501207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN397082500Medicaid
MN397082500Medicaid
MN040000164Medicare ID - Type Unspecified