Provider Demographics
NPI:1295752905
Name:NELSON, JOAN (PA-C)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
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 1:9450 SW BARNES RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6619
Mailing Address - Country:US
Mailing Address - Phone:503-292-9560
Mailing Address - Fax:503-292-9510
Practice Address - Street 1:2606 NE BROADWAY ST
Practice Address - Street 2:SUITE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1898
Practice Address - Country:US
Practice Address - Phone:503-292-9560
Practice Address - Fax:503-292-9510
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004118363A00000X
ORPA00882363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8326217Medicaid
P45063Medicare UPIN
WAG8886097Medicare PIN