1912996752 NPI number — MR. NELSON A MIN MSPT

Table of content: MR. NELSON A MIN MSPT (NPI 1912996752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912996752 NPI number — MR. NELSON A MIN MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIN
Provider First Name:
NELSON
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912996752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 RESTON PKWY
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
RESTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20190-3388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-230-1760
Provider Business Mailing Address Fax Number:
203-230-1761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 RESTON PKWY
Provider Second Line Business Practice Location Address:
SUITE 403
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20190-3388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-230-1760
Provider Business Practice Location Address Fax Number:
203-230-1761
Provider Enumeration Date:
10/14/2005

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:  2305204261 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: J1-0001744 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 701966 . This is a "NCPPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00163524-DC3456 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 249890 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7060-0001 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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