| Doctor Name: | KENNETH WILLIAM NISSEN |
| NPI Number: | 1043659980 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | ANP |
| License Number: | 306258 |
| Business Practice Address: | 75 N Country Rd Port Jefferson, NY - 117772119 |
| Business Phone Number: | 6314762786 |
| Business Fax Number: | |
| Mailing Address: | 25 Wiltshire Dr, COMMACK |
| State: | NY |
| Postal Code: | 117253330 |
| Phone Number: | 5165210456 |
| Fax Number: | |
| NPI Enumeration Date: | 06/24/2013 |
| NPI Last Update Date: | 06/24/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LA2200X |
| License Number: | 306258 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Adult Health |
| Taxonomy Definition: | |