Provider Demographics
NPI:1699785311
Name:NELSON, ROBERT GLENN (PA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GLENN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:33811 DIANA DR
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2310
Mailing Address - Country:US
Mailing Address - Phone:949-240-3457
Mailing Address - Fax:
Practice Address - Street 1:22741 LAMBERT ST
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1617
Practice Address - Country:US
Practice Address - Phone:949-581-3011
Practice Address - Fax:949-581-6457
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA10117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant