Provider Demographics
NPI:1760555445
Name:EVA NYSTROM, ARNP, PLLC
Entity Type:Organization
Organization Name:EVA NYSTROM, ARNP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EVA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NYSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:360-885-2200
Mailing Address - Street 1:PO BOX 848348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8348
Mailing Address - Country:US
Mailing Address - Phone:360-885-2200
Mailing Address - Fax:360-885-1499
Practice Address - Street 1:1405 SE 164TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9644
Practice Address - Country:US
Practice Address - Phone:360-885-2200
Practice Address - Fax:360-885-1499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004316261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP09138Medicare UPIN
WA8807333Medicare PIN