Provider Demographics
NPI:1942960935
Name:CRIST, NICK ALLEN
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:ALLEN
Last Name:CRIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4590 SCOTT TRL STE 110
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4041
Mailing Address - Country:US
Mailing Address - Phone:651-454-1000
Mailing Address - Fax:
Practice Address - Street 1:4319 CLEMSON CIR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4818
Practice Address - Country:US
Practice Address - Phone:952-484-6314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-18
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist