Healthcare Provider Details

I. General information

NPI: 1134655152
Provider Name (Legal Business Name): RYAN ALEXANDER NELSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 CREEKSIDE BLVD E UNIT 102
NAPLES FL
34109-0595
US

IV. Provider business mailing address

1285 CREEKSIDE BLVD E UNIT 102
NAPLES FL
34109-0595
US

V. Phone/Fax

Practice location:
  • Phone: 239-624-1700
  • Fax: 239-624-0311
Mailing address:
  • Phone: 239-624-1700
  • Fax: 239-624-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12496
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113002
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: