MEDICARE: NATHAN KINGSTAD PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	31803	SC

General Provider Information

NPI Number	:	1669314530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN KINGSTAD PMHNP

Provider Business Mailing Address
First Line	:	325 MATUSKOVIC DR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29414-8213
Country	:	US
Telephone Number	:	715-604-2711
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 MATUSKOVIC DR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29414-8213
Country	:	US
Telephone Number	:	715-604-2711
Fax Number	:

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

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	04/08/2026

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