Provider Demographics
NPI:1417077827
Name:NISSEN, MICHAEL D (NP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:NISSEN
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 843013
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-3013
Mailing Address - Country:US
Mailing Address - Phone:910-904-2350
Mailing Address - Fax:910-904-1037
Practice Address - Street 1:313 TEAL DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-2567
Practice Address - Country:US
Practice Address - Phone:910-904-2350
Practice Address - Fax:910-904-1037
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1061217363LF0000X
NC242756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004922Medicaid
NCNC0674AMedicare PIN