Provider Demographics
NPI:1184993586
Name:ALAN S. NELSON D.O. PC
Entity type:Organization
Organization Name:ALAN S. NELSON D.O. PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-878-8817
Mailing Address - Street 1:1404 POMERELLE AVE STE A2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2013
Mailing Address - Country:US
Mailing Address - Phone:208-878-8817
Mailing Address - Fax:208-878-3544
Practice Address - Street 1:1404 POMERELLE AVE.
Practice Address - Street 2:SUITE A2
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-878-8817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804255700Medicaid
ID1301698Medicare UPIN