Provider Demographics
NPI:1174617732
Name:NELSON, SUSAN K (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40016 EDISON DR NE
Mailing Address - Street 2:
Mailing Address - City:STANCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55080-3232
Mailing Address - Country:US
Mailing Address - Phone:701-793-4444
Mailing Address - Fax:
Practice Address - Street 1:5500 BOONE AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3629
Practice Address - Country:US
Practice Address - Phone:701-793-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1174617732Medicaid
ND11056Medicaid
NDG29996Medicare UPIN
NDN717039Medicare PIN
MN930004054Medicare PIN