Provider Demographics
NPI:1134275365
Name:NELSON, PETER N (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:N
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 1:5633 N LIDGERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-1224
Mailing Address - Country:US
Mailing Address - Phone:509-482-2448
Mailing Address - Fax:
Practice Address - Street 1:5633 N. LIDERGERWOOD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-482-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA000020435207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000362001OtherMDC PIN #
WA8570301Medicaid
WAMD00020435OtherLICENCE
WA10097730OtherMDC RR #
WA9611674Medicaid
WA9611674Medicaid
WA8570301Medicaid