Provider Demographics
NPI:1073731196
Name:NELSON, JAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:
Last Name:NELSON
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 1:1910 UNIVERSITY DR
Mailing Address - Street 2:MS-1351
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-0002
Mailing Address - Country:US
Mailing Address - Phone:208-426-1459
Mailing Address - Fax:
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:MS-1351
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-0002
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-122363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1194865444Medicare UPIN