Provider Demographics
NPI:1124537998
Name:NELSON, NICHOLAS ROY (PA-C)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ROY
Last Name:NELSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:
Practice Address - Street 1:3369 STATE ROUTE 100
Practice Address - Street 2:
Practice Address - City:MACUNGIE
Practice Address - State:PA
Practice Address - Zip Code:18062-1806
Practice Address - Country:US
Practice Address - Phone:610-402-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA217091363A00000X
PAMA059255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant