Provider Demographics
NPI:1205446895
Name:DIASSELLISS, NICHOLAS JOHN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:DIASSELLISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6521 GENERAL HAIG ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-3913
Mailing Address - Country:US
Mailing Address - Phone:504-442-2123
Mailing Address - Fax:
Practice Address - Street 1:6521 GENERAL HAIG ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-3913
Practice Address - Country:US
Practice Address - Phone:504-442-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA230640367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty