Provider Demographics
NPI:1477510493
Name:NELSON, LARRY RALPH (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:RALPH
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 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:809 S 15TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4564
Practice Address - Country:US
Practice Address - Phone:360-428-6434
Practice Address - Fax:360-428-6485
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013912207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8167603Medicaid
WA8167603Medicaid