Provider Demographics
NPI:1144202011
Name:NELSON, AVERLY H (MD)
Entity Type:Individual
Prefix:DR
First Name:AVERLY
Middle Name:H
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:EASTERN STATE HOSPITAL
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0800
Mailing Address - Country:US
Mailing Address - Phone:509-565-4000
Mailing Address - Fax:509-565-4705
Practice Address - Street 1:850 MAPLE STREET
Practice Address - Street 2:EASTERN STATE HOSPITAL
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-0800
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:509-565-4705
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000124812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1059013Medicaid
WAF04224Medicare UPIN
WA1059013Medicaid