Provider Demographics
NPI:1356333645
Name:NELSON, PAULA M (MD)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:N
Other - Last Name:NELSON-ADESOKAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:629 BEAVER RUIN RD NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3401
Mailing Address - Country:US
Mailing Address - Phone:770-921-4300
Mailing Address - Fax:770-381-6451
Practice Address - Street 1:629 BEAVER RUIN RD NW
Practice Address - Street 2:SUITE B
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3401
Practice Address - Country:US
Practice Address - Phone:770-921-4300
Practice Address - Fax:770-381-6451
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041913207N00000X, 207ND0900X
PA427315207N00000X, 207ND0900X
AL28766207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001980502Medicare PIN
GA07BBCRKMedicare ID - Type Unspecified
NJ196378YC40Medicare PIN
MD215167YD9GMedicare PIN
GA07BBCRK01Medicare PIN
PA142708V4CMedicare PIN
SCAA59939282Medicare PIN
GA07BBCRK02Medicare PIN
PA142708V4BMedicare PIN
FLEP578ZMedicare PIN
GAF88798Medicare UPIN
MD221011YEZXMedicare PIN