Provider Demographics
NPI:1619964210
Name:NELSON-NGUYEN, LISA INGRID (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:INGRID
Last Name:NELSON-NGUYEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:INGRID
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:3415 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-6976
Mailing Address - Country:US
Mailing Address - Phone:563-742-4370
Mailing Address - Fax:309-558-7026
Practice Address - Street 1:3415 53RD AVE
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-6976
Practice Address - Country:US
Practice Address - Phone:563-742-4370
Practice Address - Fax:309-558-7026
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2024-02-22
Deactivation Date:2006-01-13
Deactivation Code:
Reactivation Date:2008-04-01
Provider Licenses
StateLicense IDTaxonomies
IA01283363AM0700X
363A00000X
IL085001602363AM0700X
IA001283363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
079425OtherHEALTH ALLIANCE
IA421060724OtherBILLING TAX ID# FOR CHC
IAIA0184OtherJOHN DEERE EDI#
P06822OtherUPIN
IA5100541OtherCONTROLLED SUBSTANCE #
IA1619964210Medicaid
IA0080200Medicaid
IA42106072484OtherJOHN DEERE HEALTH
079425OtherHEALTH ALLIANCE
IA5100541OtherCONTROLLED SUBSTANCE #
079425OtherHEALTH ALLIANCE
IA421060724OtherBILLING TAX ID# FOR CHC
IA1619964210Medicaid