Provider Demographics
NPI:1508885989
Name:NELSON, SUZANNE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:PATTEN
Mailing Address - State:ME
Mailing Address - Zip Code:04765-0500
Mailing Address - Country:US
Mailing Address - Phone:207-521-0615
Mailing Address - Fax:207-528-2880
Practice Address - Street 1:59 BANGOR ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1740
Practice Address - Country:US
Practice Address - Phone:207-521-0615
Practice Address - Fax:207-528-2880
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI068760Medicaid
HI068760Medicaid