Provider Demographics
NPI:1982322079
Name:NELSON, LYDIA GRACE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:LYDIA
Middle Name:GRACE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S WIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4379
Mailing Address - Country:US
Mailing Address - Phone:217-836-8190
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-6900
Practice Address - Fax:317-880-0585
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant