Provider Demographics
NPI:1437409901
Name:NELSON, CRYSTAL A
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9350 E 35TH ST N, STE 101
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226
Mailing Address - Country:US
Mailing Address - Phone:316-265-1308
Mailing Address - Fax:316-219-4141
Practice Address - Street 1:9350 E 35TH ST N, STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-265-1308
Practice Address - Fax:316-219-4141
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01562363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical