Provider Demographics
NPI:1427208958
Name:DR GARY A NELSON PA
Entity Type:Organization
Organization Name:DR GARY A NELSON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:POSITION
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-924-7994
Mailing Address - Street 1:1001 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5337
Mailing Address - Country:US
Mailing Address - Phone:601-924-7994
Mailing Address - Fax:601-924-7671
Practice Address - Street 1:1001 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5337
Practice Address - Country:US
Practice Address - Phone:601-924-7994
Practice Address - Fax:601-924-7671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-20
Last Update Date:2008-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS082920245Medicare PIN