Basic Information
| Provider Information | |||||||||
| NPI: | 1407299423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAHORA | ||||||||
| FirstName: | NISSAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 THOMPSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 THOMPSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D84446 | MD | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 64854 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64854 | 01 | MN | LICENSE | OTHER | D84446 | 01 | MD | LICENSE | OTHER |