Provider Demographics
NPI:1700860228
Name:NEHLS, ALEXANDER B (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:B
Last Name:NEHLS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5052 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-482-5060
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5886
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-482-5060
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000797A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300006057Medicaid
INP00338087OtherRAIL ROAD MEDICARE
INP00338087Medicare PIN
IN058940SSSMedicare ID - Type Unspecified
INP00338087OtherRAIL ROAD MEDICARE