Provider Demographics
NPI:1114911971
Name:NELSON, CHRISTOPHER L (PA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4243
Mailing Address - Country:US
Mailing Address - Phone:931-783-4269
Mailing Address - Fax:931-372-0401
Practice Address - Street 1:406 N WHITNEY AVE STE 5
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4243
Practice Address - Country:US
Practice Address - Phone:931-783-4269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000452207RC0000X, 363AS0400X
TN2974363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7100424840Medicaid
TNT22988AOtherMEDICARE
TNQ020561Medicaid
TN6076339/6066808OtherBCBS
TN103I974538Medicare PIN
37945OtherTRICARE
403146OtherHEALTHLINK
085000452000OtherOSF HEALTH PLANS
IL0103OtherJOHN DEERE HEALTH PLAN
R78355Medicare UPIN
ILL96903Medicare PIN