Provider Demographics
NPI:1457666133
Name:NELSON, MARK D (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:NELSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MN
Mailing Address - Zip Code:56510-1520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 S 3RD ST W
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MN
Practice Address - Zip Code:56510-1520
Practice Address - Country:US
Practice Address - Phone:701-893-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant