Basic Information
Provider Information | |||||||||
NPI: | 1780878868 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NELSON | ||||||||
FirstName: | SHARMEEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M. D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SARKER | ||||||||
OtherFirstName: | SHARMEEN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1441 NE 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | PAYETTE | ||||||||
State: | ID | ||||||||
PostalCode: | 836615420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086429376 | ||||||||
FaxNumber: | 2086429598 | ||||||||
Practice Location | |||||||||
Address1: | 2327 SW 4TH AVE | ||||||||
Address2: |   | ||||||||
City: | ONTARIO | ||||||||
State: | OR | ||||||||
PostalCode: | 979141851 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2086429376 | ||||||||
FaxNumber: | 2086429598 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2007 | ||||||||
LastUpdateDate: | 02/07/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD126153 | OR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | FS1510088 | 01 |   | DEA NUMBER | OTHER | MD126153 | 01 | OR | OREGON LICENSE NUMBER | OTHER |