Provider Demographics
NPI:1558942383
Name:LURTSEMA, NICA ELENA (MD)
Entity type:Individual
Prefix:
First Name:NICA
Middle Name:ELENA
Last Name:LURTSEMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICA
Other - Middle Name:ELENA
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6051
Mailing Address - Country:US
Mailing Address - Phone:541-382-4900
Mailing Address - Fax:
Practice Address - Street 1:1501 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6051
Practice Address - Country:US
Practice Address - Phone:541-382-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
ORMD218776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500837469Medicaid