Healthcare Provider Details

I. General information

NPI: 1043600836
Provider Name (Legal Business Name): MR. BRUCE RODERICK NIELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 NE 194TH ST UNIT 1
RIDGEFIELD WA
98642-9496
US

IV. Provider business mailing address

800 NE TENNEY RD UNIT 110-401
VANCOUVER WA
98685-2831
US

V. Phone/Fax

Practice location:
  • Phone: 360-936-1096
  • Fax: 425-216-9433
Mailing address:
  • Phone: 425-216-9433
  • Fax: 425-216-9433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberST00001996
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberXT00004606
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberMA00153098
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNA00153098
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: