Provider Demographics
NPI:1578657706
Name:NELSON, RILEY (MD)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
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 1:01 SAGEBRUSH
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0000
Mailing Address - Country:US
Mailing Address - Phone:505-869-4863
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:01 SAGEBRUSH
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-4863
Practice Address - Fax:505-869-4881
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I04276Medicare UPIN
NM10013134Medicare ID - Type Unspecified