Provider Demographics
NPI:1477682029
Name:NELSON, AMY L (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 A MCCONNELL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-2642
Mailing Address - Country:US
Mailing Address - Phone:864-716-6050
Mailing Address - Fax:864-716-6055
Practice Address - Street 1:1922 A MCCONNELL SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2642
Practice Address - Country:US
Practice Address - Phone:864-716-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1065PAMedicaid
SC1065PAMedicaid
SCP21931Medicare UPIN