Provider Demographics
NPI:1508565169
Name:NISSEN, BRANDON LEE (DC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:NISSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 E COVEY RUN CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4273
Mailing Address - Country:US
Mailing Address - Phone:925-584-8166
Mailing Address - Fax:
Practice Address - Street 1:3381 DEER VALLEY RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-6664
Practice Address - Country:US
Practice Address - Phone:925-757-7571
Practice Address - Fax:925-757-7114
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDC36545111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor