Provider Demographics
NPI:1952381907
Name:NISHIO, WAYNE ALAN (OD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:ALAN
Last Name:NISHIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 N CLOVIS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0361
Mailing Address - Country:US
Mailing Address - Phone:559-299-3179
Mailing Address - Fax:559-299-3741
Practice Address - Street 1:145 N CLOVIS AVE STE 101
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0361
Practice Address - Country:US
Practice Address - Phone:559-299-3179
Practice Address - Fax:559-299-3741
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7298T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0072980Medicaid
CASD0072981Medicare PIN
CAT10508Medicare UPIN
CA0617680001Medicare NSC
CASD0072980Medicaid
CAP00161837Medicare PIN