Provider Demographics
NPI:1235443193
Name:NIELSEN, JUSTIN S (PAC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:S
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 CORTEZ AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7554
Mailing Address - Country:US
Mailing Address - Phone:208-523-3373
Mailing Address - Fax:208-523-8746
Practice Address - Street 1:2985 CORTEZ AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7554
Practice Address - Country:US
Practice Address - Phone:208-523-3373
Practice Address - Fax:208-523-8746
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002097363A00000X
IDPA-1255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant