Provider Demographics
NPI:1720306475
Name:NASRULLAH, NISHAT
Entity type:Individual
Prefix:
First Name:NISHAT
Middle Name:
Last Name:NASRULLAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18105 LAKEVIEW DR
Mailing Address - Street 2:UNIT 202
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5669
Mailing Address - Country:US
Mailing Address - Phone:630-709-4750
Mailing Address - Fax:
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:MS 958
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-7615
Practice Address - Fax:414-266-6238
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63853-21208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720306475Medicaid