MEDICARE: AUGUSTA JEAN NELSON ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT 655	AR
2	2255A2300X	Athletic Trainer	AT7103	TX

General Provider Information

NPI Number	:	1952797078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUGUSTA JEAN NELSON ATC

Provider Business Mailing Address
First Line	:	800 N BLUE MOUND RD
Second Line	:
City	:	SAGINAW
State	:	TX
Zip	:	76131-1052
Country	:	US
Telephone Number	:	817-306-0914
Fax Number	:	817-847-9308

Provider Business Practice Location Address
First Line	:	800 N BLUE MOUND RD
Second Line	:
City	:	SAGINAW
State	:	TX
Zip	:	76131-1052
Country	:	US
Telephone Number	:	970-819-2931
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2015
Last Update Date	:	03/29/2022

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