Healthcare Provider Details

I. General information

NPI: 1477086759
Provider Name (Legal Business Name): BRANDON THOMAS NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BYPASS RD BLDG A
PIKEVILLE KY
41501-1689
US

IV. Provider business mailing address

PO BOX 432
PIKEVILLE KY
41502-0432
US

V. Phone/Fax

Practice location:
  • Phone: 606-430-3500
  • Fax: 606-218-4697
Mailing address:
  • Phone: 606-430-3500
  • Fax: 606-218-4697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number55337
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number55337
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: