Provider Demographics
NPI:1861454191
Name:NELSON, MITCHELL PAUL (M ED; AT)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:PAUL
Last Name:NELSON
Suffix:
Gender:M
Credentials:M ED; AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 N J AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1334
Mailing Address - Country:US
Mailing Address - Phone:520-364-2447
Mailing Address - Fax:520-805-9485
Practice Address - Street 1:1500 E 15TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1731
Practice Address - Country:US
Practice Address - Phone:520-364-2447
Practice Address - Fax:520-805-9485
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer