Provider Demographics
NPI:1669437620
Name:NELSON, COLLEEN M (CRNA)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:N
Other - Last Name:PUKATCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-2025
Practice Address - Country:US
Practice Address - Phone:570-271-6621
Practice Address - Fax:570-271-5655
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN276425L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA086169Medicare ID - Type Unspecified
Q30280Medicare UPIN