Provider Demographics
NPI:1245607662
Name:NELSON, DAVID CAMERON (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CAMERON
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-0800
Mailing Address - Fax:208-302-0855
Practice Address - Street 1:6051 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8969
Practice Address - Country:US
Practice Address - Phone:208-302-5150
Practice Address - Fax:208-302-5155
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID363AM0700X
IDPA-1293363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical