Provider Demographics
NPI:1518131093
Name:NISSLY, TANNER J (DO)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:J
Last Name:NISSLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W BROADWAY AVE
Mailing Address - Street 2:BROADWAY FAMILY MEDICINE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2504
Mailing Address - Country:US
Mailing Address - Phone:612-302-8209
Mailing Address - Fax:
Practice Address - Street 1:1020 W BROADWAY AVE
Practice Address - Street 2:BROADWAY FAMILY MEDICINE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2504
Practice Address - Country:US
Practice Address - Phone:612-302-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN50925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program