Healthcare Provider Details

I. General information

NPI: 1912574377
Provider Name (Legal Business Name): MARQUES SKOT NEILSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 N 2000 W STE 101
FARR WEST UT
84404-9230
US

IV. Provider business mailing address

1055 N. 500 W. ATTN CREDENTIALING
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-528-5095
  • Fax: 801-528-5094
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number010846
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT020864
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR4167
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1421541-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: