Healthcare Provider Details

I. General information

NPI: 1104813237
Provider Name (Legal Business Name): GLENN E. NELSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 N ROSEMONT BLVD
TUCSON AZ
85712-2139
US

IV. Provider business mailing address

2308 N ROSEMONT BLVD
TUCSON AZ
85712-2139
US

V. Phone/Fax

Practice location:
  • Phone: 520-886-1176
  • Fax: 520-290-8894
Mailing address:
  • Phone: 520-886-1176
  • Fax: 520-290-8894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0310
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: