Provider Demographics
NPI:1740217389
Name:NELSON, TODD GORDON (CRNA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:GORDON
Last Name:NELSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4008
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4008
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:521 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356-9323
Practice Address - Country:US
Practice Address - Phone:360-496-5112
Practice Address - Fax:360-496-3508
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR098006952RN163W00000X
WARN00073075163W00000X
OR098006952CRNA367500000X
WAAP60786034367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2105898Medicaid
OR133069Medicare ID - Type Unspecified