Provider Demographics
NPI:1528034980
Name:NELSON, JARED WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:WILLIAM
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:701 HOSPITAL LOOP
Mailing Address - Street 2:92 MEDICAL OPERATIONS SQUADRON/SGOP
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011
Mailing Address - Country:US
Mailing Address - Phone:509-247-5661
Mailing Address - Fax:509-247-9524
Practice Address - Street 1:701 HOSPITAL LOOP
Practice Address - Street 2:92 MEDICAL GROUP
Practice Address - City:FAIRCHILD AIR FORCE BASE
Practice Address - State:WA
Practice Address - Zip Code:99011
Practice Address - Country:US
Practice Address - Phone:509-247-5661
Practice Address - Fax:509-247-9524
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287973Medicaid
OR287973Medicaid
H24238Medicare UPIN