Provider Demographics
NPI:1134283153
Name:NELSON, CHARLES L (D O)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 TORBETT ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99354-2604
Mailing Address - Country:US
Mailing Address - Phone:509-946-7646
Mailing Address - Fax:509-946-7666
Practice Address - Street 1:310 TORBETT ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2604
Practice Address - Country:US
Practice Address - Phone:509-946-7646
Practice Address - Fax:509-946-7666
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8319618Medicaid
WA0209316OtherLABOR & INDUSTRIES
WAG8865039Medicare PIN
WA0209316OtherLABOR & INDUSTRIES