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General NPI Number Information
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NPI Number | 1215926324
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Entity Type | Individual
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Provider Name | GALEN CARLOS NELSON PHYSICIAN ASSISTANT
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Gender | Male
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Dates
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Enumeration Date | 10/20/2005
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Last Update Date | 10/07/2021
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Provider Practice Location Address
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Address Line | 74 ECLIPSE CTR
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City | BELOIT
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State | WI
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Zip | 53511-3550
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Country | US
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Telephone | 608-361-6051
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Fax | 608-361-6131
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Provider Business Mailing Address
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Address Line | PO BOX 22487
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City | GREEN BAY
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State | WI
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Zip | 54305-2487
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Country | US
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Telephone | 920-445-7222
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Fax | 920-445-7289
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1133-23
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License Number State | WI
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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 | 085-001248
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License Number State | IL
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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 | 1133-023
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License Number State | WI
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