Healthcare Provider Details

I. General information

NPI: 1710044888
Provider Name (Legal Business Name): DAVID DEAN NISLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE NEUROSURGERY PA
MODESTO CA
95350-4405
US

IV. Provider business mailing address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone: 209-576-3601
  • Fax: 209-576-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 12965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: