Healthcare Provider Details

I. General information

NPI: 1275910770
Provider Name (Legal Business Name): PHILIP NIBLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 COYLE AVE
CARMICHAEL CA
95608-0306
US

IV. Provider business mailing address

3518 BODEGA CT
SACRAMENTO CA
95864-2802
US

V. Phone/Fax

Practice location:
  • Phone: 916-864-5753
  • Fax:
Mailing address:
  • Phone: 801-722-8704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA154947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: