Basic Information
| Provider Information | |||||||||
| NPI: | 1134283153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | D. O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 TORBETT ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993542604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099467646 | ||||||||
| FaxNumber: | 5099467666 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 TORBETT ST | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993542604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099467646 | ||||||||
| FaxNumber: | 5099467666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 11/23/2007 | ||||||||
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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 | 207Q00000X | OP00000752 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8319618 | 05 | WA | MEDICAID | 0209316 | 01 | WA | LABOR & INDUSTRIES | OTHER |