Provider Demographics
NPI:1588642433
Name:NELSON, JOHN RICHARD (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
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:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-242-4026
Mailing Address - Fax:541-242-4363
Practice Address - Street 1:920 COUNTRY CLUB RD
Practice Address - Street 2:STE 200A
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6024
Practice Address - Country:US
Practice Address - Phone:541-342-2134
Practice Address - Fax:541-686-6021
Is Sole Proprietor?:No
Enumeration Date:2006-01-01
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S72218Medicare UPIN
ORR136309Medicare PIN