Provider Demographics
NPI:1356846174
Name:NELSON, WALTER
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 KENSINGTON DR APT 213
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4064
Mailing Address - Country:US
Mailing Address - Phone:630-363-6324
Mailing Address - Fax:
Practice Address - Street 1:472 KENSINGTON DR APT 213
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4064
Practice Address - Country:US
Practice Address - Phone:630-363-6324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-25
Last Update Date:2018-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1701046556174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty