Provider Demographics
NPI:1609872985
Name:NELSON, J SUZANNE (PNP)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:SUZANNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 SW MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2556
Mailing Address - Country:US
Mailing Address - Phone:503-636-4508
Mailing Address - Fax:
Practice Address - Street 1:2525 NW LOVEJOY ST
Practice Address - Street 2:STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2863
Practice Address - Country:US
Practice Address - Phone:503-227-0671
Practice Address - Fax:503-227-0676
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000038085N2363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR035282Medicaid