Provider Demographics
NPI:1649438516
Name:NELLIS, RICHARD GORDON (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:GORDON
Last Name:NELLIS
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 1:20449 KOGLIN RD
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-4332
Mailing Address - Country:US
Mailing Address - Phone:612-327-2732
Mailing Address - Fax:
Practice Address - Street 1:20449 KOGLIN RD
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-4332
Practice Address - Country:US
Practice Address - Phone:612-327-2732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027096363AM0700X
MN10468363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1082853OtherNCCPA