Healthcare Provider Details

I. General information

NPI: 1295752905
Provider Name (Legal Business Name): JOAN NELSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 NE BROADWAY ST SUITE C
PORTLAND OR
97232-1898
US

IV. Provider business mailing address

9450 SW BARNES RD SUITE 100
PORTLAND OR
97225-6619
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-9560
  • Fax: 503-292-9510
Mailing address:
  • Phone: 503-292-9560
  • Fax: 503-292-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004118
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00882
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: