MEDICARE: DAVID NERSETH IRVINE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	MD15519	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6751HU	OTHER	WA	BSWA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8946238	OTHER	WA	VCR
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	0216865	OTHER	WA	LIWA

General Provider Information

NPI Number	:	1366483109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID NERSETH IRVINE MD

Provider Business Mailing Address
First Line	:	505 S 336TH ST
Second Line	:	SUITE 600
City	:	FEDERAL WAY
State	:	WA
Zip	:	98003-6328
Country	:	US
Telephone Number	:	253-838-6180
Fax Number	:	253-838-6418

Provider Business Practice Location Address
First Line	:	1809 MAPLE ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1939
Country	:	US
Telephone Number	:	503-357-2173
Fax Number	:	503-357-2318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	02/29/2008

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Directions to “ DAVID NERSETH IRVINE MD” Practice Location

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