Basic Information
| Provider Information | |||||||||
| NPI: | 1114911971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 N WHITNEY AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385014243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317834269 | ||||||||
| FaxNumber: | 9313720401 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 N WHITNEY AVE STE 5 | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385014243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317834269 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 085000452 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363A00000X | 2974 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 085000452 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 2974 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7100424840 | 05 | TN | MEDICAID | T22988A | 01 | TN | MEDICARE | OTHER | Q020561 | 05 | TN | MEDICAID | 6076339/6066808 | 01 | TN | BCBS | OTHER |