Provider Demographics
NPI:1508885021
Name:NELSON, JEFFREY W (PNP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:NELSON
Suffix:
Gender:M
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 PORTLAND AVE. SO.
Mailing Address - Street 2:MC 952
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415
Mailing Address - Country:US
Mailing Address - Phone:612-348-9840
Mailing Address - Fax:612-596-7900
Practice Address - Street 1:525 PORTLAND AVE. SO.
Practice Address - Street 2:MC 952
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415
Practice Address - Country:US
Practice Address - Phone:612-348-9840
Practice Address - Fax:612-596-7900
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9399363A00000X
MN91145363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN33D77NEOtherBLUE CROSS BLUE SHIELD
MN681325900Medicaid
MN12-01914OtherMEDICA
MN500000065Medicare Oscar/Certification
MN681325900Medicaid
MN33D77NEOtherBLUE CROSS BLUE SHIELD