Provider Demographics
NPI:1851741227
Name:NELSON, LANCE JORDAN (PT)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:JORDAN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 8TH AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4657
Mailing Address - Country:US
Mailing Address - Phone:503-387-5449
Mailing Address - Fax:503-342-6846
Practice Address - Street 1:2020 8TH AVE
Practice Address - Street 2:SUITE D
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4657
Practice Address - Country:US
Practice Address - Phone:503-387-5449
Practice Address - Fax:503-342-6846
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist