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General NPI Number Information
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NPI Number | 1093084931
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Entity Type | Individual
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Provider Name | THAO T NELSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 12/21/2011
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Last Update Date | 07/15/2021
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Provider Practice Location Address
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Address Line | 3280 E LANARK DR
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City | MERIDIAN
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State | ID
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Zip | 83642-5982
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Country | US
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Telephone | 208-895-8670
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 191050
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City | BOISE
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State | ID
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Zip | 83719-1050
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Country | US
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Telephone | 208-955-6500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 016558
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA60650168
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | OA003740
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA-1385
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License Number State | ID
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