Basic Information
| Provider Information | |||||||||
| NPI: | 1164919676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NISSLEY | ||||||||
| FirstName: | LANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109168666 | ||||||||
| FaxNumber: | 2109168712 | ||||||||
| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109168666 | ||||||||
| FaxNumber: | 2109168712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS020413 | PA | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.