1093789703 NPI number — DAVID W NELSON M.D.

Table of content: DAVID W NELSON M.D. (NPI 1093789703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093789703 NPI number — DAVID W NELSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
DAVID
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1093789703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3947
Provider Second Line Business Mailing Address:
MS 315010
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-3947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-467-3655
Provider Business Mailing Address Fax Number:
480-782-6905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135-116TH AVENUE NE
Provider Second Line Business Practice Location Address:
SUITE 605
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-454-8161
Provider Business Practice Location Address Fax Number:
425-454-6304
Provider Enumeration Date:
02/17/2006

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: 208600000X , with the licence number:  33733 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 33733 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: MD60244683 , 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: 926785 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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