Provider Demographics
NPI:1174832075
Name:NELSON, JOHN PAUL (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PAUL
Last Name:NELSON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5839 E HOPI CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6780
Mailing Address - Country:US
Mailing Address - Phone:480-833-7073
Mailing Address - Fax:
Practice Address - Street 1:2168 E WILLIAMS FIELD RD
Practice Address - Street 2:SUITE 108
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-0741
Practice Address - Country:US
Practice Address - Phone:480-899-9970
Practice Address - Fax:480-899-9972
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2442I156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2442IOtherOPTICIAN