Provider Demographics
NPI:1912014143
Name:NELSON, ERIC E (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:E
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2508
Mailing Address - Country:US
Mailing Address - Phone:415-435-7488
Mailing Address - Fax:
Practice Address - Street 1:92 MAIN ST
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-2508
Practice Address - Country:US
Practice Address - Phone:415-435-7488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT255082251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22814ZOtherMEDICARE PTAN