Basic Information
| Provider Information | |||||||||
| NPI: | 1740250331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THORDERSON | ||||||||
| FirstName: | NELS | ||||||||
| MiddleName: | WALLACE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4381 S EASON BLVD | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628405747 | ||||||||
| FaxNumber: | 6628405856 | ||||||||
| Practice Location | |||||||||
| Address1: | 4381 S EASON BLVD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628405747 | ||||||||
| FaxNumber: | 6628405856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 06/30/2011 | ||||||||
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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 | 207X00000X | 18527 | MS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01573566 | 05 | MS | MEDICAID |