Provider Demographics
NPI:1417920760
Name:NYGAARD, AIRELL LEIGHTON (MD)
Entity Type:Individual
Prefix:DR
First Name:AIRELL
Middle Name:LEIGHTON
Last Name:NYGAARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 GUZZI LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5288
Mailing Address - Country:US
Mailing Address - Phone:209-588-1800
Mailing Address - Fax:209-588-1700
Practice Address - Street 1:680 GUZZI LN
Practice Address - Street 2:SUITE 102
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5288
Practice Address - Country:US
Practice Address - Phone:209-588-1800
Practice Address - Fax:209-588-1700
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C37479207X00000X, 207XS0114X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C37479Medicaid
CA00C37479OtherCA MEDICAL LICENSE #
CA431973118OtherCORPORATE TAX ID #
CA00C37479OtherCA MEDICAL LICENSE #
CA431973118OtherCORPORATE TAX ID #