Provider Demographics
NPI:1629160080
Name:NIELSEN, TERESA (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-7530
Mailing Address - Country:US
Mailing Address - Phone:701-567-4561
Mailing Address - Fax:701-567-6361
Practice Address - Street 1:820 2ND AVE W
Practice Address - Street 2:
Practice Address - City:NEW ENGLAND
Practice Address - State:ND
Practice Address - Zip Code:58647
Practice Address - Country:US
Practice Address - Phone:701-579-4348
Practice Address - Fax:701-579-4348
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0061363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDR02166Medicare UPIN