Provider Demographics
NPI:1053075531
Name:NILSSON, AXEL
Entity type:Individual
Prefix:
First Name:AXEL
Middle Name:
Last Name:NILSSON
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 1:601 ESTRELLA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8670
Mailing Address - Country:US
Mailing Address - Phone:651-955-9010
Mailing Address - Fax:
Practice Address - Street 1:601 ESTRELLA DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-8670
Practice Address - Country:US
Practice Address - Phone:651-955-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY149998367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program