Provider Demographics
NPI:1710959432
Name:NELSON, MELINDA J (PA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:J
Last Name:NELSON
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 1:7807 SAN MIRIENDA
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78015-0007
Mailing Address - Country:US
Mailing Address - Phone:239-699-7536
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-225-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005188363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ40895Medicare UPIN
N48650055Medicare PIN
FLU4505ZMedicare ID - Type UnspecifiedMEDICARE
FLU4505YMedicare ID - Type UnspecifiedMEDICARE SOUTH GULF