Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | PT00009802 | WA |
Y | 2251X0800X | Physical Therapist - Orthopedic | 3833 | OR |
NPI | 1053353904 |
---|---|
Provider Name | Benjamin Nelson |
First Address | Portland, OR 97229-5813 |
Second Address | Portland, OR 97239-4047 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2006 |
Last Update Date | 04/04/2017 |