Healthcare Provider Details

I. General information

NPI: 1003218611
Provider Name (Legal Business Name): SCOTT NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11102 SUNRISE BLVD E STE 103
PUYALLUP WA
98374-8846
US

IV. Provider business mailing address

15217 105TH AVENUE CT E
PUYALLUP WA
98374-9748
US

V. Phone/Fax

Practice location:
  • Phone: 253-848-8797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60597789
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: