MEDICARE: LESLIE N. NISHIMI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	23775	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285689661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE N. NISHIMI M.D.

Provider Business Mailing Address
First Line	:	DEPT 2018
Second Line	:	PO BOX 29675
City	:	PHOENIX
State	:	AZ
Zip	:	85038-9675
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	77 W. FOREST AVENUE
Second Line	:	SUITE 101
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-1482
Country	:	US
Telephone Number	:	928-773-2515
Fax Number	:	928-773-2240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	04/07/2011

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