Active NPI
Ross Ellis Nisly
- Registered Nurse
- San Bernardino, CA
National Provider Identifier
1982935763
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Nurse
- License
- 550198
- Practice address
- 2080 S E St
#100
San Bernardino, CA 92408-2706 - Phone
- (909) 388-9191
- NPI assigned
- Jan 19, 2010
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | 550198 | CA | Primary |
Addresses
Primary practice location
2080 S E St
#100
San Bernardino, CA 92408-2706
Mailing address
34569 Newell St
Yucaipa, CA 92399-6864
Phone (909) 268-6900
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124100383 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 550198 | CA | MD | Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1263859200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1263859200000",
"number": "1982935763",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "34569 NEWELL ST",
"city": "YUCAIPA",
"state": "CA",
"postal_code": "923996864",
"telephone_number": "909-268-6900"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2080 S E ST",
"address_2": "#100",
"city": "SAN BERNARDINO",
"state": "CA",
"postal_code": "924082706",
"telephone_number": "909-388-9191"
}
],
"practiceLocations": [],
"basic": {
"last_name": "NISLY",
"first_name": "ROSS",
"middle_name": "ELLIS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2010-01-19",
"last_updated": "2010-01-19",
"status": "A"
},
"taxonomies": [
{
"code": "163W00000X",
"taxonomy_group": "",
"desc": "Registered Nurse",
"state": "CA",
"license": "550198",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1124100383",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in San Bernardino, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.