Provider Demographics
NPI:1477065829
Name:NELSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-6009
Mailing Address - Country:US
Mailing Address - Phone:229-395-1739
Mailing Address - Fax:
Practice Address - Street 1:4719 COOPER ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-6009
Practice Address - Country:US
Practice Address - Phone:229-395-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor