Provider Demographics
NPI:1881641686
Name:NESSAN, VERNON (MD)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:
Last Name:NESSAN
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0137
Mailing Address - Country:US
Mailing Address - Phone:253-697-5502
Mailing Address - Fax:253-697-5510
Practice Address - Street 1:702 23RD AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4661
Practice Address - Country:US
Practice Address - Phone:253-841-4378
Practice Address - Fax:253-841-5881
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013833207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1665702Medicaid
WA0155123OtherL & I PROVIDER NUMBER
WA91120349463OtherKPS PROVIDER NUMBER
WA98372K003OtherTRICARE PROVIDER NUMBER
WANE2298OtherREGENCE RIDER NUMBER
WA4330437OtherAETNA PROVIDER NUMBER
WA98372K003OtherTRICARE PROVIDER NUMBER
WA8858992Medicare ID - Type Unspecified