Provider Demographics
NPI:1134109549
Name:SELLERS, TRICIA L (MD)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:SELLERS
Suffix:
Gender:F
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:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-5316
Mailing Address - Fax:702-256-3095
Practice Address - Street 1:2704 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:702-256-3095
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059255A208000000X
NV12630208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1134109549Medicaid
BG207ZMedicare PIN