Provider Demographics
NPI:1235873803
Name:NELSON, ALLISSA MARY (PA-S)
Entity Type:Individual
Prefix:
First Name:ALLISSA
Middle Name:MARY
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 S 109TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5822
Mailing Address - Country:US
Mailing Address - Phone:918-392-1400
Mailing Address - Fax:918-392-1590
Practice Address - Street 1:4802 S 109TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5822
Practice Address - Country:US
Practice Address - Phone:918-392-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant