Provider Demographics
NPI:1083794192
Name:NELSON, MATTHEW ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:NELSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 MAXWELL DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8709
Mailing Address - Country:US
Mailing Address - Phone:715-386-9393
Mailing Address - Fax:715-386-9885
Practice Address - Street 1:1610 MAXWELL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8709
Practice Address - Country:US
Practice Address - Phone:715-386-9393
Practice Address - Fax:715-386-9885
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3008OtherSTATE DC LICENSE
MN3110OtherSTATE DC LICENSE
MN3706511Medicaid
WI38874700Medicaid
MN3110OtherSTATE DC LICENSE
WIU 44064Medicare UPIN