Provider Demographics
NPI:1275305302
Name:NELSON, ANDREW (LMT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:LMT
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 85
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:ID
Mailing Address - Zip Code:83836-0085
Mailing Address - Country:US
Mailing Address - Phone:909-486-6436
Mailing Address - Fax:
Practice Address - Street 1:30544 HIGHWAY 200 STE 326
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5042
Practice Address - Country:US
Practice Address - Phone:208-205-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-5206225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist