Basic Information
Provider Information | |||||||||
NPI: | 1487736708 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | SCOTT | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NELSON | ||||||||
OtherFirstName: | R. | ||||||||
OtherMiddleName: | SCOTT | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 191 BILTMORE AVE | ||||||||
Address2: |   | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288014109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282540881 | ||||||||
FaxNumber: | 8283503026 | ||||||||
Practice Location | |||||||||
Address1: | 191 BILTMORE AVE | ||||||||
Address2: |   | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288014109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282540881 | ||||||||
FaxNumber: | 8283503026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 09/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-00306 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1487736708 | 01 | NC | BLUE CROSS BLUE SHIELD OF NC | OTHER | 1487736708 | 01 | NC | COVENTRY HEALTH CARE, INC. | OTHER | 1487736708 | 01 | NC | MEDCOST | OTHER | MN2640945 | 01 |   | DEA | OTHER |