Provider Demographics
NPI:1235338351
Name:NELSON, ERIC W (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:W
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 1:195 MEMORIAL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 MEMORIAL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7056
Practice Address - Country:US
Practice Address - Phone:814-623-3474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053004363A00000X
MD363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA114641D1XMedicare PIN
PA0449950002Medicare NSC
MD0449950001Medicare NSC