Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 01075426A | IN |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 01075426A | IN |
NPI | 1043440852 |
---|---|
Provider Name | Ian R Nelson |
First Address | Fort Wayne, IN 46801-2526 |
Second Address | Fort Wayne, IN 46804-4133 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2009 |
Last Update Date | 03/11/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201291590 | (05) | IN |