Healthcare Provider Details

I. General information

NPI: 1417233784
Provider Name (Legal Business Name): NICHOLAS NAKAGAMA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 N MAIN ST
BOUNTIFUL UT
84010-6136
US

IV. Provider business mailing address

262 E ELLEN LN
NORTH SALT LAKE UT
84054-2304
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-2495
  • Fax: 801-298-2801
Mailing address:
  • Phone: 801-541-2130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number7786912-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: