Provider Demographics
NPI:1629387568
Name:NELSON, ISAAC EMMANUEL (LMP)
Entity Type:Individual
Prefix:MR
First Name:ISAAC
Middle Name:EMMANUEL
Last Name:NELSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 COLUMBIA PARK TRL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4711
Mailing Address - Country:US
Mailing Address - Phone:509-396-3707
Mailing Address - Fax:509-396-3710
Practice Address - Street 1:1455 COLUMBIA PARK TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4711
Practice Address - Country:US
Practice Address - Phone:509-396-3707
Practice Address - Fax:509-396-3710
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60103770225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist