Provider Demographics
NPI:1548695737
Name:NELSON, MICHAEL M (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:NELSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8429 S G ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-6316
Mailing Address - Country:US
Mailing Address - Phone:253-226-7762
Mailing Address - Fax:
Practice Address - Street 1:6004 WESTGATE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2503
Practice Address - Country:US
Practice Address - Phone:253-759-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60278671225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant