Basic Information
| Provider Information | |||||||||
| NPI: | 1225341191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | WUNKER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WUNKER | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | E. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043964893 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 LPGA BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321177131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862740250 | ||||||||
| FaxNumber: | 3862740269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2010 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9105267 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA9105267 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.