Provider Demographics
NPI:1316941834
Name:NELSON, DIANA L (PA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2437
Mailing Address - Country:US
Mailing Address - Phone:507-373-2384
Mailing Address - Fax:
Practice Address - Street 1:1000 1ST DR NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2941
Practice Address - Country:US
Practice Address - Phone:507-433-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9613363AM0700X, 363A00000X
IA1406363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970001857Medicare PIN
P33103Medicare UPIN
IAI5948Medicare PIN