Basic Information
| Provider Information | |||||||||
| NPI: | 1932817160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYSTROM | ||||||||
| FirstName: | HANNAH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 MOUNTAIN ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897033867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758821324 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 MOUNTAIN ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897033867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758821324 | ||||||||
| FaxNumber: | 7758823859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2022 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2720 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.