Provider Demographics
NPI:1235113580
Name:NELMS, MICHAEL J (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:NELMS
Suffix:
Gender:M
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 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 415
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-298-9809
Practice Address - Fax:619-298-9823
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00892151OtherRR MEDICARE -CA GROUP PTAN CD5363
CAW11117Medicare ID - Type Unspecified
CAAV153ZMedicare PIN
CAAV153XMedicare PIN
CABG109Medicare PIN
CAP00892151OtherRR MEDICARE -CA GROUP PTAN CD5363
CAWPA14379FMedicare PIN
CAAV153VMedicare PIN
CAWPA14379EMedicare PIN
CAAV153UMedicare PIN