Provider Demographics
NPI:1083727986
Name:NELSON, MICHAEL SCOTT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:NELSON
Suffix:
Gender:M
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 1:2600 FM 1764 RD
Mailing Address - Street 2:STE 190
Mailing Address - City:LA MARQUE
Mailing Address - State:TX
Mailing Address - Zip Code:77568-2826
Mailing Address - Country:US
Mailing Address - Phone:713-926-6229
Mailing Address - Fax:713-926-9292
Practice Address - Street 1:412 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77023-1840
Practice Address - Country:US
Practice Address - Phone:713-926-6229
Practice Address - Fax:713-926-9292
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1083727986OtherTRICARE SOUTH
TX187788801Medicaid
TX187788802Medicaid
TX8Y0711OtherBCBSTX PROVIDER NO
TX1083727986Medicare PIN
TX8Y0711OtherBCBSTX PROVIDER NO
TX187788802Medicaid
TX1083727986OtherTRICARE SOUTH