Provider Demographics
NPI:1447533203
Name:NELSON, GEORGE RUSTY (DPT)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:RUSTY
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1361
Mailing Address - Country:US
Mailing Address - Phone:304-647-1175
Mailing Address - Fax:304-647-3006
Practice Address - Street 1:200 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1361
Practice Address - Country:US
Practice Address - Phone:304-647-1175
Practice Address - Fax:304-647-3006
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT 002953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist