Provider Demographics
NPI:1326298787
Name:NELSON, MICHAEL LEE (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:NELSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1750 N WYMOUNT TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602-1017
Mailing Address - Country:US
Mailing Address - Phone:801-422-5156
Mailing Address - Fax:801-422-0761
Practice Address - Street 1:1750 N WYMOUNT TERRACE DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602-1017
Practice Address - Country:US
Practice Address - Phone:801-422-5156
Practice Address - Fax:801-422-0761
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4884511-1206363A00000X
SD0809363AS0400X
IDPA-2758363A00000X
IDPA-758363A00000X
IA002266363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1326298787Medicaid
SD1326298787Medicaid
IA1326298787Medicaid
SDS105876Medicare PIN
IA1326298787Medicaid