Provider Demographics
NPI:1063493088
Name:NELSON, MICHELLE R (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-656-3525
Mailing Address - Fax:262-656-3560
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-3525
Practice Address - Fax:262-656-3560
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1662023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41979800Medicaid
WI41979800Medicaid
Q02060Medicare UPIN