Provider Demographics
NPI:1003961202
Name:NELSON, AUDREY RAQUEL (PA)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:RAQUEL
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:CUSTODIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-378-3699
Practice Address - Street 1:901 HEMPHILL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3111
Practice Address - Country:US
Practice Address - Phone:817-332-4060
Practice Address - Fax:817-332-2304
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant