Provider Demographics
NPI:1790138782
Name:NELSON, RANDALL COLBY (AGNP-C)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:COLBY
Last Name:NELSON
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:250 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:REYNOLDS
Practice Address - State:GA
Practice Address - Zip Code:31076-2946
Practice Address - Country:US
Practice Address - Phone:478-825-3317
Practice Address - Fax:478-825-5499
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN248861363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health