Healthcare Provider Details

I. General information

NPI: 1508959479
Provider Name (Legal Business Name): CAROL JEAN NELSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MUNICIPAL DR
GUN BARREL CITY TX
75156-3702
US

IV. Provider business mailing address

344 NW CR 2171
BARRY TX
75102
US

V. Phone/Fax

Practice location:
  • Phone: 903-713-1511
  • Fax: 903-713-1519
Mailing address:
  • Phone: 903-229-7367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02477
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberPA02477
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: