Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NR0200X | Radiology | DC16780 | CA |
N | 213ER0200X | Radiology | DC16780 | CA |
NPI | 1720018435 |
---|---|
Provider Name | Gerald Leray Nissen |
First Address | Mojave, CA 93501-1226 |
Second Address | Mojave, CA 93501-1226 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 08/07/2007 |