1902975329 NPI number — MR. NELSON ROMAN DPT

Table of content: MR. NELSON ROMAN DPT (NPI 1902975329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902975329 NPI number — MR. NELSON ROMAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROMAN
Provider First Name:
NELSON
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1902975329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PMB 103
Provider Second Line Business Mailing Address:
425 CARR. 693 STE 1
Provider Business Mailing Address City Name:
DORADO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00646-9817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-262-3007
Provider Business Mailing Address Fax Number:
787-854-7021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CLINICAL LAS VEGAS
Provider Second Line Business Practice Location Address:
CARR #2 KM 46.4 EDIF. LAS VEGAS 420
Provider Business Practice Location Address City Name:
MANATI
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-854-7021
Provider Business Practice Location Address Fax Number:
787-854-7021
Provider Enumeration Date:
11/07/2006

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: 174400000X , with the licence number:  1212 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 1212 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 039100100 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




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