Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | G046205 | CA |
N | 111NI0900X | Internist | G046205 | CA |
Y | 207RA0201X | Internist - Allergy & Immunology | G046205 | CA |
NPI | 1649269614 |
---|---|
Provider Name | Dr. Bruce Leslie Nelson |
First Address | Mission Viejo, CA 92691-6384 |
Second Address | Mission Viejo, CA 92691-6384 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2005 |
Last Update Date | 06/11/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G462050 | (05) | CA |
E04627 | (02) | CA |