Provider Demographics
NPI:1528524774
Name:NELSON, MARY KATHERINE (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1919 S WHEELING AVE
Mailing Address - Street 2:LL
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104
Mailing Address - Country:US
Mailing Address - Phone:918-748-7890
Mailing Address - Fax:918-293-3137
Practice Address - Street 1:1919 S WHEELING AVE STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5637
Practice Address - Country:US
Practice Address - Phone:918-748-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2957363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical