Provider Demographics
NPI:1790244457
Name:NELSON, TASHA L
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:L
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S SIBLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-3030
Mailing Address - Country:US
Mailing Address - Phone:320-693-3233
Mailing Address - Fax:320-693-3290
Practice Address - Street 1:520 S SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-3030
Practice Address - Country:US
Practice Address - Phone:320-693-3233
Practice Address - Fax:320-693-3290
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant