Provider Demographics
NPI:1972919405
Name:NELSON, STEPHEN (PT, DPT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5090 SHOREHAM PL STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5934
Mailing Address - Country:US
Mailing Address - Phone:206-228-3787
Mailing Address - Fax:858-455-5000
Practice Address - Street 1:5090 SHOREHAM PL STE 109
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5934
Practice Address - Country:US
Practice Address - Phone:206-228-3787
Practice Address - Fax:858-455-5000
Is Sole Proprietor?:No
Enumeration Date:2014-07-04
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist