=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164763330
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATALIE R NELSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2013
-----------------------------------------------------
Last Update Date | 03/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1614 S BYRNE RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43614-3464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-385-5751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12331 WATERSTONE LN APT 706
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-3045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-220-7497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 003729
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------