MEDICARE: MICHAEL D NISSEN N.P.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	242756	NC
2	363LF0000X	Family Nurse Practitioner	11026653	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417077827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D NISSEN N.P.-C

Provider Business Mailing Address
First Line	:	3399 FERRIS CIR
Second Line	:
City	:	VERNON
State	:	FL
Zip	:	32462-2217
Country	:	US
Telephone Number	:	706-594-6919
Fax Number	:

Provider Business Practice Location Address
First Line	:	3399 FERRIS CIR
Second Line	:
City	:	VERNON
State	:	FL
Zip	:	32462-2217
Country	:	US
Telephone Number	:	706-594-6919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	11/05/2024

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