Provider Demographics
NPI:1992799662
Name:NELSON, JOHN ANDREW (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANDREW
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 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:1500 S DOBSON RD STE 202
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4724
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-974-2673
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0105OtherJOHN DEERE HEALTH PLANS
IL05732036OtherBLUE SHIELD GROUP NUMBERT
068816OtherHEALTH ALLIANCE PROVIDER
085000447003OtherOSF HEALTH PLANS
661684OtherHEALTHLINK
37945OtherTIRCARE
661684OtherHEALTHLINK
ILK41306Medicare PIN