Provider Demographics
NPI:1760465298
Name:NIELSEN, JOHN WILLIAM (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:NIELSEN
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1901 S 17TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6626
Mailing Address - Country:US
Mailing Address - Phone:910-343-8424
Mailing Address - Fax:910-343-6989
Practice Address - Street 1:1901 S 17TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6626
Practice Address - Country:US
Practice Address - Phone:910-343-8424
Practice Address - Fax:910-343-6989
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2011-01-11
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Provider Licenses
StateLicense IDTaxonomies
NC101766363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S81621Medicare UPIN
NC2747268BMedicare ID - Type Unspecified