Provider Demographics
NPI:1649221912
Name:NELSON, MATTHEW R (PA C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
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 1:2375 E SUNNYSIDE RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8280
Mailing Address - Country:US
Mailing Address - Phone:208-522-7246
Mailing Address - Fax:208-529-2620
Practice Address - Street 1:2375 E SUNNYSIDE RD STE J
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8281
Practice Address - Country:US
Practice Address - Phone:208-522-7246
Practice Address - Fax:208-529-2620
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807285000Medicaid
ID807285000Medicaid
1667133Medicare ID - Type Unspecified