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General NPI Number Information
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NPI Number | 1760046130
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Entity Type | Individual
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Provider Name | NELSON ERIK VICK MD
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Gender | Male
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Dates
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Enumeration Date | 04/30/2019
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Last Update Date | 06/16/2023
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Provider Practice Location Address
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Address Line | 9040A JACKSON AVENUE
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City | JOINT BASE LEWIS MCCHORD
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State | WA
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Zip | 98431-0004
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Country | US
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Telephone | 253-968-3496
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Fax |
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Provider Business Mailing Address
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Address Line | 5406 BALUSTRADE BLVD SE
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City | LACEY
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State | WA
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Zip | 98513-5032
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Country | US
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Telephone | 651-271-6519
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD61351689
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License Number State | WA
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