Provider Demographics
NPI:1932488053
Name:NELSON, CAMERON LEWIS
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:LEWIS
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CAMERON
Other - Middle Name:LEWIS
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1799
Mailing Address - Country:US
Mailing Address - Phone:208-785-4100
Mailing Address - Fax:
Practice Address - Street 1:1553 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4135
Practice Address - Country:US
Practice Address - Phone:208-233-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
IDPA-1556363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01159224Medicaid
CO368305YL2GMedicare PIN