Provider Demographics
NPI:1053313312
Name:NENSTIEL, RICHARD O (PAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:O
Last Name:NENSTIEL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 AIRPORT BLVD
Mailing Address - Street 2:SUITE D146
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608
Mailing Address - Country:US
Mailing Address - Phone:251-633-5155
Mailing Address - Fax:251-633-5125
Practice Address - Street 1:1040 GULF BREEZE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7808
Practice Address - Country:US
Practice Address - Phone:850-916-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-143363A00000X, 363AS0400X
FLPA9115249363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51540426OtherBC
AL009942453Medicaid
AL051540426Medicare PIN
Q05658Medicare UPIN