Provider Demographics
NPI:1336398304
Name:NYSTROM, LAUREN M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:M
Last Name:NYSTROM
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 1:2290 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2929
Mailing Address - Country:US
Mailing Address - Phone:707-643-5785
Mailing Address - Fax:707-643-8190
Practice Address - Street 1:1700 2ND ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-2445
Practice Address - Country:US
Practice Address - Phone:707-252-2931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19925363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant