Basic Information
| Provider Information | |||||||||
| NPI: | 1457514192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSEN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ERIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644357 | ||||||||
| FaxNumber: | 3154642030 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644357 | ||||||||
| FaxNumber: | 3154642030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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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 | 208000000X | 245637 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 03237905 | 05 | NY | MEDICAID |