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NPI Code Detail

MEDICARE: ETHAN DANIEL NELSON

MEDICARE: ETHAN DANIEL NELSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy AssistantA2889MN

General Provider Information

NPI Number : 1326826033
Entity Type Code : Individual
Provider Name (Legal Business Name) : ETHAN DANIEL NELSON
Provider Business Mailing Address
First Line : 1613 TAYLOR AVE W
Second Line :
City : SAINT PAUL
State : MN
Zip : 55104-1241
Country : US
Telephone Number : 651-354-6105
Fax Number :
Provider Business Practice Location Address
First Line : 1670 LEGACY PKWY E
Second Line :
City : MAPLEWOOD
State : MN
Zip : 55109-5469
Country : US
Telephone Number : 651-756-1859
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/15/2023
Last Update Date : 09/19/2023

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