MEDICARE: MR. RICK LEE NISSEN 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	207YS0123X	Facial Plastic Surgery Physician	30501	MN

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	:	1306842711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICK LEE NISSEN M.D.

Provider Business Mailing Address
First Line	:	8714 LYNDALE AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55420-2738
Country	:	US
Telephone Number	:	952-948-9695
Fax Number	:	952-948-9086

Provider Business Practice Location Address
First Line	:	8714 LYNDALE AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55420-2738
Country	:	US
Telephone Number	:	952-948-9695
Fax Number	:	952-948-9086

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	02/25/2013

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