Provider Demographics
NPI:1437584752
Name:NELSON, MATTHEW GLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GLEN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-737-6718
Mailing Address - Fax:
Practice Address - Street 1:725 FAIR ST
Practice Address - Street 2:
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316-6442
Practice Address - Country:US
Practice Address - Phone:208-543-8271
Practice Address - Fax:208-543-8272
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1267363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1437584752OtherEMI HEALTH
UT148464OtherPEHP
UTP01239491OtherRAILROAD MEDICARE
UT5606757OtherAETNA HEALTHCARE
ID1374811Medicare Oscar/Certification
UT148464OtherPEHP