Healthcare Provider Details

I. General information

NPI: 1861454191
Provider Name (Legal Business Name): MITCHELL PAUL NELSON M. ED.; A.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E 15TH ST
DOUGLAS AZ
85607-1731
US

IV. Provider business mailing address

1704 N J AVE
DOUGLAS AZ
85607-1334
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-2447
  • Fax: 520-805-9485
Mailing address:
  • Phone: 520-364-2447
  • Fax: 520-805-9485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0649
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: