Provider Demographics
NPI:1265535629
Name:NELSON, ROBERT HUGO (PAC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:HUGO
Last Name:NELSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 ARROWSIC RD
Mailing Address - Street 2:
Mailing Address - City:ARROWSIC
Mailing Address - State:ME
Mailing Address - Zip Code:04530
Mailing Address - Country:US
Mailing Address - Phone:207-448-9623
Mailing Address - Fax:
Practice Address - Street 1:123 MEDICAL CENTER DR
Practice Address - Street 2:MID COAST HOSPITAL
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-373-6086
Practice Address - Fax:207-373-6080
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA595363AS0400X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00033Medicare UPIN
MEAP1191Medicare ID - Type Unspecified