Provider Demographics
NPI:1477637890
Name:NELSON, ROBERT BRUCE (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRUCE
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 1:825 E GATE BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2136
Mailing Address - Country:US
Mailing Address - Phone:516-804-5200
Mailing Address - Fax:
Practice Address - Street 1:1500 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-1045
Practice Address - Country:US
Practice Address - Phone:516-877-2400
Practice Address - Fax:516-877-1897
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01564227Medicaid
NYS76284Medicare UPIN
NYS76284Medicare UPIN