1063582211 NPI number — MARY Q NELSON MPT

Table of content: MARY Q NELSON MPT (NPI 1063582211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063582211 NPI number — MARY Q NELSON MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
MARY
Provider Middle Name:
Q
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHERN
Provider Other First Name:
MARY
Provider Other Middle Name:
Q
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063582211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 731269
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98373-0060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-840-2313
Provider Business Mailing Address Fax Number:
253-840-6340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5605 100TH ST SW
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-284-9800
Provider Business Practice Location Address Fax Number:
253-284-9801
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00009699 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 194913 . This is a "DEPT OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7954671 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8904739 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1542NE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8419178 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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