Provider Demographics
NPI:1285710988
Name:NILSSON, GARY (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:NILSSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 CANTON STREET
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2329
Mailing Address - Country:US
Mailing Address - Phone:781-407-7713
Mailing Address - Fax:781-451-0998
Practice Address - Street 1:455 TOLLGATE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2759
Practice Address - Country:US
Practice Address - Phone:401-738-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRNA20382367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RINR40830Medicaid
RI7009144Medicare ID - Type Unspecified
RI007058970Medicare PIN