Provider Demographics
NPI:1164996922
Name:NYSTED, CANDACE (PA-C)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:NYSTED
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 LAKE HAVASU AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-9309
Mailing Address - Country:US
Mailing Address - Phone:928-453-1970
Mailing Address - Fax:833-450-5461
Practice Address - Street 1:309 LAKE HAVASU AVE S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-9309
Practice Address - Country:US
Practice Address - Phone:928-453-1970
Practice Address - Fax:833-450-5461
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9280363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant