Provider Demographics
NPI:1538137245
Name:NELSEN, LISA K (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:NELSEN
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
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 396
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-0396
Mailing Address - Country:US
Mailing Address - Phone:916-780-1107
Mailing Address - Fax:916-780-7007
Practice Address - Street 1:151 N SUNRISE AVE
Practice Address - Street 2:SUITE 1009
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2924
Practice Address - Country:US
Practice Address - Phone:916-782-3792
Practice Address - Fax:916-781-6562
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAO62910207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A629100Medicaid
CA00A629100Medicaid