Provider Demographics
NPI:1992979454
Name:SHIELDS, NICOLE PAULSON (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:PAULSON
Last Name:SHIELDS
Suffix:
Gender:F
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 367
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-0367
Mailing Address - Country:US
Mailing Address - Phone:423-869-7193
Mailing Address - Fax:423-869-7195
Practice Address - Street 1:424 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6606
Practice Address - Country:US
Practice Address - Phone:423-869-7193
Practice Address - Fax:423-869-7195
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000615Medicaid