Healthcare Provider Details

I. General information

NPI: 1730400649
Provider Name (Legal Business Name): JASON WAYNE NIELSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 N LA CANADA DR STE 2
GREEN VALLEY AZ
85614-4380
US

IV. Provider business mailing address

1930 N LA CANADA DR STE 2
GREEN VALLEY AZ
85614-4380
US

V. Phone/Fax

Practice location:
  • Phone: 520-545-0592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number54209
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number56825
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: