Provider Demographics
NPI:1992909766
Name:NELSON, WAYNE K (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:K
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 NE 27TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7728
Mailing Address - Country:US
Mailing Address - Phone:541-313-8111
Mailing Address - Fax:541-313-8112
Practice Address - Street 1:1550 NE 27TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7728
Practice Address - Country:US
Practice Address - Phone:541-313-8111
Practice Address - Fax:541-313-8112
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1798208D00000X
390200000X
ORMD1613302086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDPS F0163850OtherTEXAS DPS NUMBER
ORP01229162OtherMEDICARE RAILROAD
OR500659802Medicaid
TXN1798OtherTEXAS MEDICAL LISCENSE
ORMD161330OtherOREGON MEDICAL LISCENSE
TXN1798OtherTEXAS MEDICAL LISCENSE