Provider Demographics
NPI:1710071071
Name:NELSON, SANDRA K (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
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 1:707 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414
Mailing Address - Country:US
Mailing Address - Phone:307-578-2500
Mailing Address - Fax:307-578-2492
Practice Address - Street 1:424 YELLOWSTONE AVE.
Practice Address - Street 2:STE 220
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414
Practice Address - Country:US
Practice Address - Phone:307-578-2500
Practice Address - Fax:307-578-2492
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI506112084P0804X
WY9486A2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34916000Medicaid
IDIP805843700Medicaid
000010029939OtherBLUE CROSS BLUE SHIELD
MT35564OtherMONTANA MEDICAID
ID39859OtherBLUE CROSS
WI34916000Medicaid