Provider Demographics
NPI:1962940304
Name:NELSON, MARK ALAN (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7934 NATIVE DANCER TRL
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-6470
Mailing Address - Country:US
Mailing Address - Phone:720-987-7481
Mailing Address - Fax:
Practice Address - Street 1:436 5TH AVE
Practice Address - Street 2:MEDICAL SERVICES, MANIILAQ HEALTH CENTER
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:907-442-7148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK119037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant