Healthcare Provider Details

I. General information

NPI: 1932509072
Provider Name (Legal Business Name): AMANDA JO NELSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3516 ELM AVE APT 408
LONG BEACH CA
90807-3916
US

IV. Provider business mailing address

3516 ELM AVE APT 408
LONG BEACH CA
90807-3916
US

V. Phone/Fax

Practice location:
  • Phone: 310-514-6525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number51860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: