Provider Demographics
NPI:1891791356
Name:NELSON, JEAN MARIE (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3686
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-0686
Mailing Address - Country:US
Mailing Address - Phone:910-442-1100
Mailing Address - Fax:910-442-1199
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-442-1100
Practice Address - Fax:910-442-1199
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35997207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2177982IOtherMEDICARE PTAN
NC2177982GOtherMEDICARE PTAN
NC891108UMedicaid
NC1992708747Medicare PIN
NC2177982IOtherMEDICARE PTAN
NC2177982GOtherMEDICARE PTAN