MEDICARE: DR. NADINE STACY-MARIE LYSEIGHT 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	207V00000X	Obstetrics & Gynecology Physician	A79351	CA

General Provider Information

NPI Number	:	1790785046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NADINE STACY-MARIE LYSEIGHT M.D.

Provider Business Mailing Address
First Line	:	1850 N RIVERSIDE AVE STE 180
Second Line	:
City	:	RIALTO
State	:	CA
Zip	:	92376-8071
Country	:	US
Telephone Number	:	909-787-1987
Fax Number	:	877-553-0133

Provider Business Practice Location Address
First Line	:	1850 N RIVERSIDE AVE STE 180
Second Line	:
City	:	RIALTO
State	:	CA
Zip	:	92376-8071
Country	:	US
Telephone Number	:	909-787-1987
Fax Number	:	877-553-0133

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	08/19/2022

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