Healthcare Provider Details

I. General information

NPI: 1184863193
Provider Name (Legal Business Name): CHARLES ANTHONY NELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 HILDEBRAND LN NE STE 100
BAINBRIDGE ISLAND WA
98110-2887
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-991-2121
  • Fax: 206-991-2151
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60171773
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: