Basic Information
| Provider Information | |||||||||
| NPI: | 1750541942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYSTROM | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 855 N WESTHAVEN DR | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203038700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2008 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | OS12697 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 5101017624 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 68888-21 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P01408649 | 01 | FL | RAILROAD MEDICARE | OTHER | 013076600 | 05 | FL | MEDICAID | 14V7E | 01 | FL | BCBS FL | OTHER |