Provider Demographics
NPI:1306825294
Name:NELSON, EVAN L JR (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:L
Last Name:NELSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:3517 FAIRWAY RIDGE LN SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-2865
Practice Address - Country:US
Practice Address - Phone:507-993-3987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15994207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN040002665OtherRAILROAD MEDICARE
MN553382100Medicaid
IAENROLLEDMedicaid
MN040000176Medicare PIN
IAENROLLEDMedicaid