Provider Demographics
NPI:1770558991
Name:NUCKLOS, PAULA L (M D)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:L
Last Name:NUCKLOS
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 HORSELYDOWN CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3308 HORSELYDOWN CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-7616
Practice Address - Country:US
Practice Address - Phone:804-364-7009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010211280Medicaid
VA010211280Medicaid
VA008584P95 - C03895Medicare ID - Type Unspecified