Provider Demographics
NPI:1730278276
Name:NELSON, TAMARA QUINLAN (DC)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:QUINLAN
Last Name:NELSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TAMARA
Other - Middle Name:JO
Other - Last Name:QUINLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:534 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1790
Mailing Address - Country:US
Mailing Address - Phone:612-720-4805
Mailing Address - Fax:612-206-8595
Practice Address - Street 1:1310 HIGHWAY 96 E STE 212
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3619
Practice Address - Country:US
Practice Address - Phone:612-720-4805
Practice Address - Fax:612-206-8595
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3604111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN618323900Medicaid
MN618323900Medicaid
MN97G19CAOtherBCBSOUTNETWORK
MNU82673Medicare UPIN
MN97G19CAOtherBCBSOUTNETWORK