Basic Information
| Provider Information | |||||||||
| NPI: | 1518590058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JAMES RODNEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1680 DIAGONAL RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561871008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073723800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1680 DIAGONAL RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561871008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073723800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2020 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.