Provider Demographics
NPI:1316976814
Name:NELSON, KEVIN F (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:F
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 1:3533 MATLOCK RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3604
Mailing Address - Country:US
Mailing Address - Phone:817-419-0303
Mailing Address - Fax:817-468-5963
Practice Address - Street 1:3533 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3604
Practice Address - Country:US
Practice Address - Phone:817-419-0303
Practice Address - Fax:817-468-5963
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15815363A00000X
WI1850-023363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP69604Medicare UPIN
WIK400251786Medicare Oscar/Certification
WI000107027Medicare PIN
WIK400270323Medicare Oscar/Certification