Basic Information
| Provider Information | |||||||||
| NPI: | 1043591597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4262 OLD WILLIAM PENN HWY STE 109 | ||||||||
| Address2: | |||||||||
| City: | MURRYSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156681954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243256010 | ||||||||
| FaxNumber: | 7243274690 | ||||||||
| Practice Location | |||||||||
| Address1: | 4262 OLD WILLIAM PENN HWY STE 109 | ||||||||
| Address2: | |||||||||
| City: | MURRYSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156681954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243256010 | ||||||||
| FaxNumber: | 7243274690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2011 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD442925 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102632018 | 05 | PA | MEDICAID |