Provider Demographics
NPI:1730293960
Name:NELSON, JOAN D
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:D
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21265
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-1265
Mailing Address - Country:US
Mailing Address - Phone:254-741-1185
Mailing Address - Fax:254-741-1249
Practice Address - Street 1:3000 HERRING AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3239
Practice Address - Country:US
Practice Address - Phone:254-741-1185
Practice Address - Fax:254-741-1249
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX430868367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109743801Medicaid
TX109743804Medicaid
TX88523UOtherBCBS
TX109743804Medicaid
TX84759CMedicare PIN