Provider Demographics
NPI:1134218969
Name:NYQUIST, BROCK VICTOR (CRNA, MSN)
Entity type:Individual
Prefix:MR
First Name:BROCK
Middle Name:VICTOR
Last Name:NYQUIST
Suffix:
Gender:M
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 E 2ND ST
Mailing Address - Street 2:#8
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5072
Mailing Address - Country:US
Mailing Address - Phone:562-439-1609
Mailing Address - Fax:
Practice Address - Street 1:902 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4218
Practice Address - Country:US
Practice Address - Phone:562-544-8804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA489087367500000X
CA3079367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered