Provider Demographics
NPI:1922103407
Name:NELSON, BRADY PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADY
Middle Name:PAUL
Last Name:NELSON
Suffix:
Gender:M
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 1:13943 N. 91ST AVE BUILDING I
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3692
Mailing Address - Country:US
Mailing Address - Phone:623-815-2690
Mailing Address - Fax:623-815-2689
Practice Address - Street 1:13943 N . 91ST AVE BUILDING I
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3692
Practice Address - Country:US
Practice Address - Phone:623-815-2690
Practice Address - Fax:623-815-2689
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2677363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ736077Medicaid
AZ2677Medicaid