Provider Demographics
NPI:1730891284
Name:NELSON, KEVIN M
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COADY CT
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4189
Mailing Address - Country:US
Mailing Address - Phone:510-410-1709
Mailing Address - Fax:
Practice Address - Street 1:1162 MONTGOMERY DR FL 2
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4802
Practice Address - Country:US
Practice Address - Phone:707-890-4100
Practice Address - Fax:707-476-2237
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical