Provider Demographics
NPI:1659325033
Name:NELSON, DEREK M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:M
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 1:810 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:NE
Mailing Address - Zip Code:68008-1128
Mailing Address - Country:US
Mailing Address - Phone:402-426-2182
Mailing Address - Fax:402-426-1190
Practice Address - Street 1:810 N 22ND ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-1128
Practice Address - Country:US
Practice Address - Phone:402-426-2182
Practice Address - Fax:402-426-1190
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE30694OtherBLUE CROSS
NE10025300500Medicaid
NE10025355300Medicaid
12350231OtherCAQH
12350231OtherCAQH
NE30694OtherBLUE CROSS
NEMN1082990OtherDEA NUMBER
NEQ13881Medicare UPIN
NE283487Medicare ID - Type UnspecifiedRURAL HEALTH