Healthcare Provider Details

I. General information

NPI: 1376524355
Provider Name (Legal Business Name): ANTON STEPHAN NESSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
U S A F ACADEMY CO
80840-2502
US

IV. Provider business mailing address

4005 WALKER RD
COLORADO SPRINGS CO
80908-2347
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5117
  • Fax:
Mailing address:
  • Phone: 719-487-7485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number42417
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: