Healthcare Provider Details

I. General information

NPI: 1174043038
Provider Name (Legal Business Name): PETER NATHANAEL NELSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44555 WOODWARD AVE SUITE 305
PONTIAC MI
48341
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-3812
  • Fax: 248-858-3815
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008208
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: