Provider Demographics
NPI:1568653152
Name:LARRY R NELSON M.D. INC P.S.
Entity Type:Organization
Organization Name:LARRY R NELSON M.D. INC P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-736-0713
Mailing Address - Street 1:1401 MARVIN RD NE STE 307-266
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5709
Mailing Address - Country:US
Mailing Address - Phone:360-491-5055
Mailing Address - Fax:360-491-5890
Practice Address - Street 1:1800 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9068
Practice Address - Country:US
Practice Address - Phone:360-736-0713
Practice Address - Fax:360-330-8680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA25290013431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty