Healthcare Provider Details

I. General information

NPI: 1164612024
Provider Name (Legal Business Name): JASON LYNN NELLES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 PALMER DR SUITE 201
CAMERON PARK CA
95682-8276
US

IV. Provider business mailing address

PO BOX 45680
SAN FRANCISCO CA
94145-0680
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9488
  • Fax:
Mailing address:
  • Phone: 530-626-9488
  • Fax: 530-748-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA125671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: