Provider Demographics
NPI:1609875871
Name:NELSON, HEIDI LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LEIGH
Last Name:NELSON
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5652
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:1107 HWY 395
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410
Practice Address - Country:US
Practice Address - Phone:775-782-1600
Practice Address - Fax:775-782-1633
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10546207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXPY197920Medicaid
NV100503301Medicaid
CA00A833380Medicaid
CA00A833381Medicare PIN
CA00A833382Medicare PIN
CA00A833380Medicaid
H06927Medicare UPIN