Healthcare Provider Details

I. General information

NPI: 1568901080
Provider Name (Legal Business Name): NELSON JAMIR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 08/28/2021
Certification Date: 08/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N EISENHOWER ST
MOSCOW ID
83843-9588
US

IV. Provider business mailing address

1215 S MOUNTAIN VIEW RD APT 102
MOSCOW ID
83843-3283
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-6560
  • Fax:
Mailing address:
  • Phone: 308-214-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1565
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5400
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: