MEDICARE: LISA K NELSEN MEDICAL DOCTOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	AO62910	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538137245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA K NELSEN MEDICAL DOCTOR

Provider Business Mailing Address
First Line	:	PO BOX 396
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95678-0396
Country	:	US
Telephone Number	:	916-780-1107
Fax Number	:	916-780-7007

Provider Business Practice Location Address
First Line	:	151 N SUNRISE AVE
Second Line	:	SUITE 1009
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2924
Country	:	US
Telephone Number	:	916-782-3792
Fax Number	:	916-781-6562

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	02/25/2020

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