Provider Demographics
NPI:1073241279
Name:NELSON, TERRANCE DEVON (CPC)
Entity Type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:DEVON
Last Name:NELSON
Suffix:
Gender:M
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 E FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99217-7063
Mailing Address - Country:US
Mailing Address - Phone:509-638-2236
Mailing Address - Fax:
Practice Address - Street 1:901 N MONROE ST STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2148
Practice Address - Country:US
Practice Address - Phone:509-715-8302
Practice Address - Fax:509-241-1866
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61250259175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG61250259Medicaid