Provider Demographics
NPI:1043600836
Name:NIELSON, BRUCE RODERICK
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:RODERICK
Last Name:NIELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 NE TENNEY RD
Mailing Address - Street 2:UNIT 110-401
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2831
Mailing Address - Country:US
Mailing Address - Phone:425-216-9433
Mailing Address - Fax:425-216-9433
Practice Address - Street 1:415 NE 194TH ST
Practice Address - Street 2:UNIT 1
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-9496
Practice Address - Country:US
Practice Address - Phone:360-936-1096
Practice Address - Fax:425-216-9433
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAST00001996246ZS0410X
WAXT00004606247100000X
WAMA00153098247200000X
WANA00153098376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No376K00000XNursing Service Related ProvidersNurse's Aide