Provider Demographics
NPI:1164996922
Name:NYSTED, CANDACE (PA-C)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:NYSTED
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 LOCUST LN
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6820
Mailing Address - Country:US
Mailing Address - Phone:701-653-5242
Mailing Address - Fax:
Practice Address - Street 1:3003 AZ-95
Practice Address - Street 2:SUITE 101
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-758-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer