Healthcare Provider Details

I. General information

NPI: 1053696344
Provider Name (Legal Business Name): ANTHONY DOMINIC NELSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16390 N 59TH AVE SUITE 200
GLENDALE AZ
85306
US

IV. Provider business mailing address

16390 N 59TH AVE STE 200
GLENDALE AZ
85306-1711
US

V. Phone/Fax

Practice location:
  • Phone: 623-334-4000
  • Fax: 623-334-4400
Mailing address:
  • Phone: 623-334-4000
  • Fax: 623-334-4400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: