Provider Demographics
NPI:1093765034
Name:NELSON, MICHAEL MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MARK
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4700 POINT FOSDICK DR NW STE 219
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1706
Mailing Address - Country:US
Mailing Address - Phone:253-851-7733
Mailing Address - Fax:253-851-8060
Practice Address - Street 1:4700 POINT FOSDICK DR NW STE 219
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335
Practice Address - Country:US
Practice Address - Phone:253-851-7733
Practice Address - Fax:253-851-8060
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60058324207N00000X, 207N00000X
MN103373207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I55155Medicare UPIN