Provider Demographics
NPI:1376761437
Name:NELSON, AURELIA (MD)
Entity Type:Individual
Prefix:
First Name:AURELIA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-426-3005
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:MS 1351
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-0002
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:208-426-3005
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6523208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1376761437Medicaid
ID20003548Medicare PIN
ID20003549Medicare PIN
IDF97754Medicare UPIN
ID1376761437Medicaid
ID20003546Medicare PIN
ID20003545Medicare PIN