Healthcare Provider Details

I. General information

NPI: 1508885021
Provider Name (Legal Business Name): JEFFREY W NELSON PNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 PORTLAND AVE. SO. MC 952
MINNEAPOLIS MN
55415
US

IV. Provider business mailing address

525 PORTLAND AVE. SO. MC 952
MINNEAPOLIS MN
55415
US

V. Phone/Fax

Practice location:
  • Phone: 612-348-9840
  • Fax: 612-596-7900
Mailing address:
  • Phone: 612-348-9840
  • Fax: 612-596-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9399
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number91145
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: