Provider Demographics
NPI:1396059440
Name:NASSERY, KRISTEN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MARIE
Last Name:NASSERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:BLAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3601 VISTA WAY STE 203
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4559
Mailing Address - Country:US
Mailing Address - Phone:760-724-5352
Mailing Address - Fax:760-724-5447
Practice Address - Street 1:3601 VISTA WAY STE 203
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4559
Practice Address - Country:US
Practice Address - Phone:760-724-5352
Practice Address - Fax:760-724-5447
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA141260208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery