Healthcare Provider Details

I. General information

NPI: 1649340985
Provider Name (Legal Business Name): LARRY JAY NUSSBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 NEIL RD 215
RENO NV
89502-6599
US

IV. Provider business mailing address

401 W 2ND ST SUITE 235D
RENO NV
89503-5345
US

V. Phone/Fax

Practice location:
  • Phone: 775-784-4917
  • Fax: 775-784-1428
Mailing address:
  • Phone: 775-382-8175
  • Fax: 775-327-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5131
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: