Basic Information
| Provider Information | |||||||||
| NPI: | 1811971021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISBET | ||||||||
| FirstName: | FANNY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 W PRINCE RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857053526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207929890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 W PRINCE RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857053526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206703909 | ||||||||
| FaxNumber: | 5203887170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 20324 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 096322 | 05 | AZ | MEDICAID |