Provider Demographics
NPI:1750317293
Name:NISBET, WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:NISBET
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 1:960 LIBERTY ST SE STE 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4165
Mailing Address - Country:US
Mailing Address - Phone:503-364-5033
Mailing Address - Fax:503-364-4820
Practice Address - Street 1:960 LIBERTY ST SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4165
Practice Address - Country:US
Practice Address - Phone:503-364-5033
Practice Address - Fax:503-364-4820
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10771174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR13769-5Medicaid
OR13769-5Medicaid