Basic Information
| Provider Information | |||||||||
| NPI: | 1790816015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | DIANE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7163629518 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 S UNION ST | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147603676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163722229 | ||||||||
| FaxNumber: | 7163722225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012348 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2550 | 01 | AZ | AZ LICENSE | OTHER |