Provider Demographics
NPI:1104811603
Name:NELSON, SHAUN (PA)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4202
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:120 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4201
Practice Address - Country:US
Practice Address - Phone:502-855-7200
Practice Address - Fax:502-855-7201
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300040820Medicaid
KY95004735Medicaid
KY100508KYIPOtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
KY2268718OtherWELLCARE OF KY PROVIDER ID NUMBER
000001408313OtherANTHEM PROVIDER ID NUMBER
CS2026900168OtherCARESOURCE PROVIDER ID NUMBER