Provider Demographics
NPI:1447488135
Name:NELSON, DANIEL ANTHONY (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ANTHONY
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
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 428
Mailing Address - Street 2:625 EAST BROADWAY
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-733-3636
Mailing Address - Fax:
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-733-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8910A207P00000X
IL125056159390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY134940600Medicaid