Provider Demographics
NPI:1346270865
Name:FLISS, NICOLE JUSTINE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JUSTINE
Last Name:FLISS
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 1:1830 EVANGELINE LN
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-1395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-2857
Practice Address - Country:US
Practice Address - Phone:907-269-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066122207Q00000X
AK4107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKP00825315OtherMEDICARE RAILROAD
MI1346270865Medicaid
AKMD41072Medicaid
AK0361450001Medicare NSC
MIN38430023Medicare Oscar/Certification
AKK162670Medicare PIN
G34633Medicare UPIN