Basic Information
| Provider Information | |||||||||
| NPI: | 1336499383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 PEELER ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490082300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693458618 | ||||||||
| FaxNumber: | 2693451508 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 PEELER ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490082300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693458618 | ||||||||
| FaxNumber: | 2693451508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2012 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704295064 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 4704295064 | 01 | MI | MICHIGAN LICENSE | OTHER |