Provider Demographics
NPI:1154437366
Name:NELSON, CYNTHIA (DO)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 AIRLINE HWY
Mailing Address - Street 2:SUITE F., PMB 157
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5634
Mailing Address - Country:US
Mailing Address - Phone:831-637-5873
Mailing Address - Fax:831-637-1290
Practice Address - Street 1:930 SUNSET DR
Practice Address - Street 2:BUILDING 1, SUITE A
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5780
Practice Address - Country:US
Practice Address - Phone:831-637-5873
Practice Address - Fax:831-637-1290
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE50093Medicare UPIN
CAZZZ28849ZMedicare ID - Type Unspecified