Provider Demographics
NPI:1962548065
Name:NISSLEY, PAUL (CRNA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:NISSLEY
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 1:1504 SANTA ROSA RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5109
Mailing Address - Country:US
Mailing Address - Phone:804-288-4453
Mailing Address - Fax:804-288-1621
Practice Address - Street 1:1602 SKIPWITH RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5205
Practice Address - Country:US
Practice Address - Phone:804-289-4937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001088658367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008726A17Medicare PIN