MEDICARE: MS. AMANDA JO NELSON PA-C

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
1	363A00000X	Physician Assistant	51860	CA

General Provider Information

NPI Number	:	1932509072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMANDA JO NELSON PA-C

Provider Business Mailing Address
First Line	:	3516 ELM AVE APT 408
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3916
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3516 ELM AVE APT 408
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3916
Country	:	US
Telephone Number	:	310-514-6525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2014
Last Update Date	:	05/04/2016

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