Provider Demographics
NPI:1427118975
Name:NELSON, NOELLE M (MD)
Entity type:Individual
Prefix:
First Name:NOELLE
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:8100 W 78TH ST # ST100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2516
Practice Address - Country:US
Practice Address - Phone:952-914-8100
Practice Address - Fax:952-914-8101
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41692207R00000X
MN64916208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN629628900Medicaid
MN629628900Medicaid
H14221Medicare UPIN