Provider Demographics
NPI:1326298787
Name:NELSON, MICHAEL LEE (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
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 1:575 N SIOUX POINT RD
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5312
Mailing Address - Country:US
Mailing Address - Phone:605-217-2667
Mailing Address - Fax:605-217-2900
Practice Address - Street 1:1888 W 800 N
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-4097
Practice Address - Country:US
Practice Address - Phone:801-610-7321
Practice Address - Fax:801-610-7306
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-758363A00000X
IA002266363AS0400X
SD0809363AS0400X
UT4884511-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1326298787Medicaid
NE1326298787Medicaid
IA1326298787Medicaid
SDS105876Medicare PIN
IA1326298787Medicaid