Provider Demographics
NPI:1225341191
Name:NELSON, KRISTIN WUNKER (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:WUNKER
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:E
Other - Last Name:WUNKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:1890 LPGA BLVD STE 250
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7131
Practice Address - Country:US
Practice Address - Phone:386-274-0250
Practice Address - Fax:386-274-0269
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105267363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFD397ZMedicare PIN