Provider Demographics
NPI:1548560071
Name:NELSON, WILLIAM ORTAN (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ORTAN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3550
Mailing Address - Fax:681-342-3507
Practice Address - Street 1:527 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9010
Practice Address - Country:US
Practice Address - Phone:681-342-3550
Practice Address - Fax:681-342-3507
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV0343BOtherMEDICARE PTAN