Provider Demographics
NPI:1184863193
Name:NELSON, CHARLES ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:945 HILDEBRAND LN NE STE 100
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2887
Practice Address - Country:US
Practice Address - Phone:206-991-2121
Practice Address - Fax:206-991-2151
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60171773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine