Healthcare Provider Details

I. General information

NPI: 1790244457
Provider Name (Legal Business Name): TASHA L NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S SIBLEY AVE
LITCHFIELD MN
55355-3030
US

IV. Provider business mailing address

520 S SIBLEY AVE
LITCHFIELD MN
55355-3030
US

V. Phone/Fax

Practice location:
  • Phone: 320-693-3233
  • Fax: 320-693-3290
Mailing address:
  • Phone: 320-693-3233
  • Fax: 320-693-3290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12954
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: