Provider Demographics
NPI:1295843886
Name:NELSON, CORY J
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:J
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:MT
Mailing Address - Zip Code:59859-0768
Mailing Address - Country:US
Mailing Address - Phone:406-826-4800
Mailing Address - Fax:406-826-4816
Practice Address - Street 1:10 KRUGER RD
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:MT
Practice Address - Zip Code:59859-9506
Practice Address - Country:US
Practice Address - Phone:406-826-4800
Practice Address - Fax:406-826-4816
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT35436367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT412509Medicaid
MT271323Medicare Oscar/Certification