Provider Demographics
NPI:1851745483
Name:NELSON, WADE
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 FEARN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-2515
Mailing Address - Country:US
Mailing Address - Phone:925-519-2487
Mailing Address - Fax:
Practice Address - Street 1:1821 FEARN AVE
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-2515
Practice Address - Country:US
Practice Address - Phone:925-519-2487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39562183500000X
CO12777183500000X
IA17272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist