Provider Demographics
NPI:1609405471
Name:NISWANDER, CAMERON RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:RAYMOND
Last Name:NISWANDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:505-368-6025
Practice Address - Street 1:US HWY 491 N
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-9998
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:505-368-6025
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61486397207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program