Provider Demographics
NPI:1750586772
Name:NELSON, JACQUELINE D (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
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 1:820 5TH ST N
Mailing Address - Street 2:PO BOX 79
Mailing Address - City:CARRINGTON
Mailing Address - State:ND
Mailing Address - Zip Code:58421-1223
Mailing Address - Country:US
Mailing Address - Phone:701-652-2515
Mailing Address - Fax:701-652-3595
Practice Address - Street 1:820 5TH ST N
Practice Address - Street 2:
Practice Address - City:CARRINGTON
Practice Address - State:ND
Practice Address - Zip Code:58421
Practice Address - Country:US
Practice Address - Phone:701-652-2515
Practice Address - Fax:701-652-3595
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0368363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical