MEDICARE: KRISTIN WUNKER NELSON P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9105267	FL
2	363AS0400X	Surgical Physician Assistant	PA9105267	FL

General Provider Information

NPI Number	:	1225341191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN WUNKER NELSON P.A.

Provider Business Mailing Address
First Line	:	11945 SAN JOSE BLVD STE 300
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-1627
Country	:	US
Telephone Number	:	904-396-1725
Fax Number	:	904-396-4893

Provider Business Practice Location Address
First Line	:	1890 LPGA BLVD STE 250
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-7131
Country	:	US
Telephone Number	:	386-274-0250
Fax Number	:	386-274-0269

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2010
Last Update Date	:	03/10/2020

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