Provider Demographics
NPI:1821417353
Name:NELSON, MICHAEL BRENT (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRENT
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1630 ANDERSON AVENUE SUITE 100
Mailing Address - Street 2:WHITESELL MEDICAL STAFFING, LTD.
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313
Mailing Address - Country:US
Mailing Address - Phone:763-682-5906
Mailing Address - Fax:
Practice Address - Street 1:1630 ANDERSON AVE STE 100
Practice Address - Street 2:WHITESELL MEDICAL STAFFING, LTD.
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2946
Practice Address - Country:US
Practice Address - Phone:763-682-5906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine