Healthcare Provider Details

I. General information

NPI: 1376502773
Provider Name (Legal Business Name): DAVID MICHAEL NISSENBAUM MPT MA LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 05/31/2025
Certification Date: 05/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 MAIN ST STE A
CROSS PLAINS WI
53528-9477
US

IV. Provider business mailing address

1118 MAIN ST STE A
CROSS PLAINS WI
53528-9477
US

V. Phone/Fax

Practice location:
  • Phone: 608-413-0550
  • Fax: 608-413-0552
Mailing address:
  • Phone: 608-413-0550
  • Fax: 608-413-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number209039
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6391024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: