Healthcare Provider Details

I. General information

NPI: 1700860228
Provider Name (Legal Business Name): ALEXANDER B NEHLS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 N CLINTON ST
FORT WAYNE IN
46825-5886
US

IV. Provider business mailing address

5052 N CLINTON ST
FORT WAYNE IN
46825-5822
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-8551
  • Fax: 260-482-5060
Mailing address:
  • Phone: 260-484-8551
  • Fax: 260-482-5060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000797A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: