Provider Demographics
NPI:1902067242
Name:NELSON, BROOKE TAYLOR (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:TAYLOR
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602381
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 VANDERBILT PARK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-1700
Practice Address - Country:US
Practice Address - Phone:828-274-6000
Practice Address - Fax:828-274-6025
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200179363AM0700X
NC0010-06664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA.200179OtherPHSICIAN ASSISTANT LICENSE