Provider Demographics
NPI:1679257927
Name:GRISALES, NICOLAS
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:GRISALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 83 BOX 6615
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-9778
Mailing Address - Country:US
Mailing Address - Phone:603-289-6980
Mailing Address - Fax:
Practice Address - Street 1:55 CALLE PALMA
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-4526
Practice Address - Country:US
Practice Address - Phone:787-650-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR110085367500000X
FL11027970367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered