Basic Information
| Provider Information | |||||||||
| NPI: | 1609803600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSEN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 834 SHERIDAN ST | ||||||||
| Address2: | |||||||||
| City: | PORT TOWNSEND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983682443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603851252 | ||||||||
| FaxNumber: | 3603351252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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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 | 207PE0004X | MD00027873 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 1081NE | 01 | WA | BSWA | OTHER | 8153439 | 05 | WA | MEDICAID |