Provider Demographics
NPI:1508887688
Name:EHLY, NELSON RICHARD (PA)
Entity Type:Individual
Prefix:MR
First Name:NELSON
Middle Name:RICHARD
Last Name:EHLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:EHLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 2723
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27802-2723
Mailing Address - Country:US
Mailing Address - Phone:252-446-3333
Mailing Address - Fax:252-446-0426
Practice Address - Street 1:111 S FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-6971
Practice Address - Country:US
Practice Address - Phone:252-446-3333
Practice Address - Fax:252-446-0426
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015A5Medicaid
NC89015A5Medicaid
NC89015A5Medicaid