Provider Demographics
NPI:1174039978
Name:YOUNG, NELSEN WILLIAM (SFIDC)
Entity Type:Individual
Prefix:
First Name:NELSEN
Middle Name:WILLIAM
Last Name:YOUNG
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 CAMINO DE LA REINA APT 360
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3270
Mailing Address - Country:US
Mailing Address - Phone:661-718-9201
Mailing Address - Fax:
Practice Address - Street 1:206 NEPTUNE STREET
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5136
Practice Address - Country:US
Practice Address - Phone:619-537-3371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-17
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman