Provider Demographics
NPI:1306950076
Name:NELSON, LARRY DEAN (PA-C)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
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:PO BOX 60122
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0122
Mailing Address - Country:US
Mailing Address - Phone:704-373-0212
Mailing Address - Fax:704-373-1216
Practice Address - Street 1:1001 BLYTHE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5863
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:704-373-1216
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101010363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0194PAMedicaid
P00245252OtherRAILROAD MEDICARE
S73295Medicare UPIN
SC0194PAMedicaid