Provider Demographics
NPI:1770583437
Name:NELSON, LISA DEE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DEE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DEE
Other - Last Name:GAMINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 36900
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-6900
Mailing Address - Country:US
Mailing Address - Phone:702-732-6000
Mailing Address - Fax:702-243-7531
Practice Address - Street 1:2950 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2204
Practice Address - Country:US
Practice Address - Phone:702-732-6000
Practice Address - Fax:702-243-7531
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV83882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV300124878Medicaid
NV35535Medicare ID - Type Unspecified
H51019Medicare UPIN
NV300124878Medicaid