Provider Demographics
NPI:1083955694
Name:NELSON, TIMOTHY N (LAC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:N
Last Name:NELSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8034 NE HOLLADAY ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6871
Mailing Address - Country:US
Mailing Address - Phone:971-227-2773
Mailing Address - Fax:
Practice Address - Street 1:2917 NE EVERETT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3248
Practice Address - Country:US
Practice Address - Phone:971-227-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC161759171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist