Provider Demographics
NPI:1871396051
Name:NISSAN, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:NISSAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:SANDS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2621
Mailing Address - Country:US
Mailing Address - Phone:516-456-1448
Mailing Address - Fax:
Practice Address - Street 1:664 STONELEIGH AVE STE 301
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-3990
Practice Address - Country:US
Practice Address - Phone:845-790-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program