Basic Information
| Provider Information | |||||||||
| NPI: | 1699822536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYQUIST | ||||||||
| FirstName: | GURSTON | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 CHESTNUT ST FL 6 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556760 | ||||||||
| FaxNumber: | 2159234532 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 CHESTNUT ST FL 6 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556760 | ||||||||
| FaxNumber: | 2159234532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 12/31/2018 | ||||||||
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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 | 207Y00000X | 247362 | NY | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | MD445760 | PA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0308773 | 05 | NJ | MEDICAID | 102725618 | 05 | PA | MEDICAID |