Provider Demographics
NPI:1083302087
Name:NELSON, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:NELSON
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 1:1409 N WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1249
Mailing Address - Country:US
Mailing Address - Phone:612-695-5925
Mailing Address - Fax:
Practice Address - Street 1:1409 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1249
Practice Address - Country:US
Practice Address - Phone:612-695-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program