Healthcare Provider Details

I. General information

NPI: 1558293811
Provider Name (Legal Business Name): NICKOLAS ALEXANDER URBAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 N 1100 E
AMERICAN FORK UT
84003-2090
US

IV. Provider business mailing address

6624 W DESERT WASH WAY
HERRIMAN UT
84096-5778
US

V. Phone/Fax

Practice location:
  • Phone: 801-855-3625
  • Fax:
Mailing address:
  • Phone: 801-367-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11583572-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: