Provider Demographics
NPI:1285855270
Name:NIELSON, CURTIS SAMUEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CURTIS
Middle Name:SAMUEL
Last Name:NIELSON
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12811 TRIPLE CROWN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5039
Mailing Address - Country:US
Mailing Address - Phone:208-241-4909
Mailing Address - Fax:
Practice Address - Street 1:1404 POMERELLE AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2012
Practice Address - Country:US
Practice Address - Phone:208-878-8783
Practice Address - Fax:208-878-8786
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-610363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP38089Medicare UPIN