MEDICARE: SHAUN NELSON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA842	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	100508KYIP	OTHER	KY	AETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
4	2268718	OTHER	KY	WELLCARE OF KY PROVIDER ID NUMBER
5	000001408313	OTHER		ANTHEM PROVIDER ID NUMBER
6	CS2026900168	OTHER		CARESOURCE PROVIDER ID NUMBER

General Provider Information

NPI Number	:	1104811603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUN NELSON PA

Provider Business Mailing Address
First Line	:	223 EXECUTIVE PARK
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4202
Country	:	US
Telephone Number	:	502-907-0356
Fax Number	:	502-919-9780

Provider Business Practice Location Address
First Line	:	120 EXECUTIVE PARK
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4201
Country	:	US
Telephone Number	:	502-855-7200
Fax Number	:	502-855-7201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	04/14/2022

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Directions to “ SHAUN NELSON PA” Practice Location

Language	Start Address	Practice Location

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