Provider Demographics
NPI:1619936457
Name:NELSON, LISA (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
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 5849
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89513-5849
Mailing Address - Country:US
Mailing Address - Phone:775-770-2043
Mailing Address - Fax:
Practice Address - Street 1:2375 E PRATER WAY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-9641
Practice Address - Country:US
Practice Address - Phone:775-331-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV778207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016200Medicaid
NV201660023Medicaid
NV002016200Medicaid
NVF05071Medicare UPIN