Provider Demographics
NPI:1720018435
Name:NISSEN, GERALD LERAY (DC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LERAY
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 1:16916 STATE HIGHWAY 14
Mailing Address - Street 2:
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93501-1226
Mailing Address - Country:US
Mailing Address - Phone:661-824-9732
Mailing Address - Fax:661-824-1638
Practice Address - Street 1:16916 STATE HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1226
Practice Address - Country:US
Practice Address - Phone:661-824-9732
Practice Address - Fax:661-824-1638
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16780111NR0200X
CARHC1261372471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111NR0200XChiropractic ProvidersChiropractorRadiology
Not Answered2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography