Healthcare Provider Details

I. General information

NPI: 1629987748
Provider Name (Legal Business Name): JOHN NISPEROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6940 PACIFIC AVE
STOCKTON CA
95207-2602
US

IV. Provider business mailing address

4705 DAHLIA DR
STOCKTON CA
95212-2117
US

V. Phone/Fax

Practice location:
  • Phone: 209-477-4817
  • Fax:
Mailing address:
  • Phone: 805-206-0596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: