Provider Demographics
NPI:1811025257
Name:NELSON, SUELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:SUELLEN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
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 1:969 MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1791
Mailing Address - Country:US
Mailing Address - Phone:845-896-7730
Mailing Address - Fax:
Practice Address - Street 1:969 MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524
Practice Address - Country:US
Practice Address - Phone:845-896-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000463363AS0400X
NY003700363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400085151OtherMEDICARE PTAN
NY04956290Medicaid
NYA400085151OtherMEDICARE PTAN