Provider Demographics
NPI:1124662259
Name:NEILSON, GARRETT AUSTIN
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:AUSTIN
Last Name:NEILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NW LOCUST ST # C411
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2751
Mailing Address - Country:US
Mailing Address - Phone:425-894-3035
Mailing Address - Fax:
Practice Address - Street 1:600 NW LOCUST ST # C411
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2751
Practice Address - Country:US
Practice Address - Phone:425-894-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60968675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60968675OtherDEPARTMENT OF HEALTH