Provider Demographics
NPI:1881650802
Name:NYSTROM, JOEL ERIK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:ERIK
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 DONATION RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-7601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 EDGEWOOD DRIVE EXT
Practice Address - Street 2:
Practice Address - City:TRANSFER
Practice Address - State:PA
Practice Address - Zip Code:16154-1817
Practice Address - Country:US
Practice Address - Phone:724-962-3553
Practice Address - Fax:724-962-3630
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 018376E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD018376EOtherSTATE LICENSE
PAMD018376EOtherSTATE LICENSE