Basic Information
| Provider Information | |||||||||
| NPI: | 1841299385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 36500 AURORA DR | ||||||||
| Address2: | STE 430 | ||||||||
| City: | SUMMIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546779 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36500 AURORA DR | ||||||||
| Address2: | STE 430 | ||||||||
| City: | SUMMIT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530664899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546779 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 9509 | NV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002003754 | 05 | NV | MEDICAID | 00G857910 | 05 | CA | MEDICAID | XPY193917 | 05 | CA | MEDICAID |