Provider Demographics
NPI:1568570430
Name:NELSON, PHILIP B (PA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:B
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 1:2120 L ST NW STE 450
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-1541
Mailing Address - Country:US
Mailing Address - Phone:202-741-2904
Mailing Address - Fax:
Practice Address - Street 1:2120 L ST NW STE 450
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037
Practice Address - Country:US
Practice Address - Phone:202-741-2904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC893363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q02992Medicare UPIN
SCAA0208Medicare ID - Type Unspecified