Healthcare Provider Details

I. General information

NPI: 1275854242
Provider Name (Legal Business Name): DEREK JAMES NELSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 SMITH AVE N STE 220
SAINT PAUL MN
55102-2459
US

IV. Provider business mailing address

PO BOX 74008272
CHICAGO IL
60674-8272
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-8295
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR8924
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number54534
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: