Provider Demographics
NPI:1386733541
Name:NELLERMOE, MARK DALE (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DALE
Last Name:NELLERMOE
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:3929 BRIDGEPORT WAY W STE 308
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4455
Mailing Address - Country:US
Mailing Address - Phone:253-627-4181
Mailing Address - Fax:253-272-5922
Practice Address - Street 1:3929 BRIDGEPORT WAY W STE 308
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4455
Practice Address - Country:US
Practice Address - Phone:253-627-4181
Practice Address - Fax:253-272-5922
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPO00000507213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB02027OtherMEDICARE ID
WA1102375Medicaid
WA990007694OtherRAILROAD MEDICARE ID
WA0039635OtherDEPARTMENT OF LABOR & IND
WA1386733541OtherNPI #
WA1386733541OtherNPI #