Provider Demographics
NPI:1659396042
Name:NELSON, ANDREW JACK III (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JACK
Last Name:NELSON
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:936 12TH PL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1436
Mailing Address - Country:US
Mailing Address - Phone:928-778-7996
Mailing Address - Fax:928-442-3324
Practice Address - Street 1:936 12TH PL
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1436
Practice Address - Country:US
Practice Address - Phone:928-778-7996
Practice Address - Fax:928-442-3324
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ76783Medicare PIN
AZ76782Medicare ID - Type UnspecifiedGIN
AZ94751Medicare UPIN