Basic Information
| Provider Information | |||||||||
| NPI: | 1083015580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 CLERMONT ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033998020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2914 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596272849 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2014 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 0000543 | CO | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | E5347 | CA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.