=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750586772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE D NELSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2007
-----------------------------------------------------
Last Update Date | 08/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 5TH ST N
-----------------------------------------------------
City | CARRINGTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-652-2515
-----------------------------------------------------
Fax | 701-652-3595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 5TH ST N PO BOX 79
-----------------------------------------------------
City | CARRINGTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58421-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-652-2515
-----------------------------------------------------
Fax | 701-652-3595
-----------------------------------------------------
=====================================================
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 | PAC0368
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PAC0368
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------