Provider Demographics
NPI:1033115183
Name:NELSON, PAMELA (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 HEALTH PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8242
Mailing Address - Country:US
Mailing Address - Phone:269-655-3065
Mailing Address - Fax:269-655-0588
Practice Address - Street 1:451 HEALTH PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8242
Practice Address - Country:US
Practice Address - Phone:269-655-3065
Practice Address - Fax:269-655-0588
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1033115183Medicaid
MI2386001OtherMEDICARE RURAL HEALTH CLINIC NUMBER
CO05538068Medicaid
CO05538068Medicaid
MI2386001OtherMEDICARE RURAL HEALTH CLINIC NUMBER
524648Medicare ID - Type Unspecified