Basic Information
| Provider Information | |||||||||
| NPI: | 1609875871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435652 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 HWY 395 | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821600 | ||||||||
| FaxNumber: | 7757821633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 04/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 10546 | NV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | XPY197920 | 05 | CA | MEDICAID | 100503301 | 05 | NV | MEDICAID | 00A833380 | 05 | CA | MEDICAID |