Healthcare Provider Details

I. General information

NPI: 1649221912
Provider Name (Legal Business Name): MATTHEW R NELSON PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 E SUNNYSIDE RD STE J
IDAHO FALLS ID
83404-8281
US

IV. Provider business mailing address

2375 E SUNNYSIDE RD SUITE J
IDAHO FALLS ID
83404-8280
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-7246
  • Fax: 208-529-2620
Mailing address:
  • Phone: 208-522-7246
  • Fax: 208-529-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA540
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: