Healthcare Provider Details

I. General information

NPI: 1235618497
Provider Name (Legal Business Name): DAVID WESLEY NELSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 BLACKSTONE BLVD
PROVIDENCE RI
02906-4829
US

IV. Provider business mailing address

455 TOLL GATE RD PRC AND CREDENTIALING
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-455-6200
  • Fax: 401-455-6689
Mailing address:
  • Phone: 401-273-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01074
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01074
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: