Healthcare Provider Details

I. General information

NPI: 1225317399
Provider Name (Legal Business Name): MUSAB EM T NUSRAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 S WEBSTER AVE
GREEN BAY WI
54301-2253
US

IV. Provider business mailing address

3601 4TH ST MS 9410
LUBBOCK TX
79430-9410
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone: 806-743-3155
  • Fax: 806-743-3143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number68185-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: