Healthcare Provider Details

I. General information

NPI: 1720306475
Provider Name (Legal Business Name): NISHAT NASRULLAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE MS 958
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

18105 LAKEVIEW DR UNIT 202
BROOKFIELD WI
53045-5669
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-7615
  • Fax: 414-266-6238
Mailing address:
  • Phone: 630-709-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number63853-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: