Healthcare Provider Details

I. General information

NPI: 1598725970
Provider Name (Legal Business Name): BRIAN D NISKANEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

IV. Provider business mailing address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

V. Phone/Fax

Practice location:
  • Phone: 320-679-1212
  • Fax:
Mailing address:
  • Phone: 320-679-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number44785
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: