Provider Demographics
NPI:1669356762
Name:NELSON, DEIRDRE (PA-C)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
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 1:56 INWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:POINT LOOKOUT
Mailing Address - State:NY
Mailing Address - Zip Code:11569-3017
Mailing Address - Country:US
Mailing Address - Phone:516-384-2242
Mailing Address - Fax:
Practice Address - Street 1:1468 MADISON AVE
Practice Address - Street 2:GP 5W
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6508
Practice Address - Country:US
Practice Address - Phone:212-241-8867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-01
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant