Provider Demographics
NPI:1457889909
Name:GUNASEKERA, NICOLE (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:GUNASEKERA
Suffix:
Gender:F
Credentials:MD, MBA
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 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:505-368-6027
Practice Address - Street 1:US HWY 491 N
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-9998
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:505-368-6027
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA286727207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology