Basic Information
| Provider Information | |||||||||
| NPI: | 1831197607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192724300 | ||||||||
| FaxNumber: | 3192724411 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507034407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192724300 | ||||||||
| FaxNumber: | 3192724411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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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 | 207Q00000X | 36749 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0076372 | 05 | IA | MEDICAID | 21827 | 01 | IA | WELLMARK | OTHER | 21828 | 01 | IA | WELLMARK | OTHER | 0731935 | 05 | IA | MEDICAID | 1731935 | 05 | IA | MEDICAID |