Healthcare Provider Details

I. General information

NPI: 1063453405
Provider Name (Legal Business Name): NICOLE NELSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 PLEASANT ST SUITE 205
CONCORD NH
03301-2548
US

IV. Provider business mailing address

246 PLEASANT ST SUITE 205
CONCORD NH
03301-2548
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-0584
  • Fax: 603-225-5769
Mailing address:
  • Phone: 603-224-0584
  • Fax: 603-225-5769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0404
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0404
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: