Healthcare Provider Details

I. General information

NPI: 1578182184
Provider Name (Legal Business Name): NICHOLAS ROBERT SELISKAR NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 TOWNE CENTRE RD
SAGINAW MI
48604-2834
US

IV. Provider business mailing address

4092 HEATHERMOOR DR
SAGINAW MI
48603-1194
US

V. Phone/Fax

Practice location:
  • Phone: 989-790-2600
  • Fax:
Mailing address:
  • Phone: 989-928-5202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number4704276691
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704276691
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704276691
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: