Individual
GARY ALAN NISIUS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
15655 37TH AVE N STE 100, PLYMOUTH, MN 55446-4003
(763) 587-7900
(763) 587-7701
Mailing address
9201 W BROADWAY AVE STE 601, BROOKLYN PARK, MN 55445-1924
(763) 587-7900
(763) 587-7066
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
41693
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
940521600
—
MN
Enumeration date
06/30/2006
Last updated
11/08/2022
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