Provider Demographics
NPI:1861771099
Name:ELAM, PAUL GREGORY (PTA)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:GREGORY
Last Name:ELAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 S 126TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2047
Mailing Address - Country:US
Mailing Address - Phone:402-216-4895
Mailing Address - Fax:
Practice Address - Street 1:4809 REDMAN AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-1842
Practice Address - Country:US
Practice Address - Phone:402-455-5025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE353314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility