Basic Information
| Provider Information | |||||||||
| NPI: | 1730110206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | MARVIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O.,PHARM.D.,M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420662203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708047710 | ||||||||
| FaxNumber: | 2708047722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 02797 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 261QP2300X | 02797KY | KY | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 64071806 | 05 | KY | MEDICAID |