Provider Demographics
NPI:1508147232
Name:NISSEN, DUSTIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:L
Last Name:NISSEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4530 E MUIRWOOD DR
Mailing Address - Street 2:#105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7639
Mailing Address - Country:US
Mailing Address - Phone:480-961-2303
Mailing Address - Fax:480-961-2306
Practice Address - Street 1:4530 E MUIRWOOD DR
Practice Address - Street 2:#105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7639
Practice Address - Country:US
Practice Address - Phone:480-961-2303
Practice Address - Fax:480-961-2306
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2014-09-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ48734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR72957OtherTRAINING PERMIT