Provider Demographics
NPI:1295991073
Name:NAZZAL, MAISA A (MD)
Entity type:Individual
Prefix:DR
First Name:MAISA
Middle Name:A
Last Name:NAZZAL
Suffix:
Gender:F
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 315
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63022-0315
Mailing Address - Country:US
Mailing Address - Phone:419-508-6851
Mailing Address - Fax:
Practice Address - Street 1:555 N NEW BALLAS RD STE 210
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6844
Practice Address - Country:US
Practice Address - Phone:314-993-4949
Practice Address - Fax:314-993-4945
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036147677207RN0300X
OK29008207RN0300X
ARE7470207RN0300X
MO2016012961207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200033362Medicaid
OK200545180AMedicaid