Provider Demographics
NPI:1801814892
Name:NELSON, LARRY R (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:R
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 1:1401 MARVIN RD NE
Mailing Address - Street 2:SUITE 307 PMB 266
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:98531-9072
Practice Address - Country:US
Practice Address - Phone:360-736-0713
Practice Address - Fax:360-330-8680
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA252-9 0013431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA14818OtherL&I WORKERS COMP
WA1625003Medicaid
WAL00240OtherBLUE CROSS/BLUE SHIELD
WA1625003Medicaid