Provider Demographics
NPI:1629035795
Name:NELSON, GARY E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:E
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 1:150 E CENTER ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-3106
Mailing Address - Country:US
Mailing Address - Phone:801-374-7011
Mailing Address - Fax:801-374-7009
Practice Address - Street 1:150 E CENTER ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3106
Practice Address - Country:US
Practice Address - Phone:801-374-7011
Practice Address - Fax:801-374-7009
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105991-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05664Medicaid
UT000061294Medicare PIN
UT000061293Medicare PIN
UTS48215Medicare UPIN
UT005521101Medicare ID - Type Unspecified