Provider Demographics
NPI:1295120921
Name:NELSON, MATTHEW TANNER (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TANNER
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 AUTUMN LAKE CV
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4464
Mailing Address - Country:US
Mailing Address - Phone:270-625-8178
Mailing Address - Fax:
Practice Address - Street 1:1201 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9811
Practice Address - Country:US
Practice Address - Phone:270-417-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04493207P00000X
390200000X
PAOS019090207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program