Provider Demographics
NPI:1679219422
Name:NEVELS, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:NEVELS
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 1:105 SKYLARK DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0043
Mailing Address - Country:US
Mailing Address - Phone:190-369-1572
Mailing Address - Fax:
Practice Address - Street 1:105 SKYLARK DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0043
Practice Address - Country:US
Practice Address - Phone:903-691-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver