Healthcare Provider Details

I. General information

NPI: 1073557583
Provider Name (Legal Business Name): NATHAN B ELIASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 11/27/2023
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 W 5300 S
MURRAY UT
84123-5671
US

IV. Provider business mailing address

677 W 5300 S
MURRAY UT
84123-5671
US

V. Phone/Fax

Practice location:
  • Phone: 801-327-8700
  • Fax: 801-290-2847
Mailing address:
  • Phone: 801-327-8700
  • Fax: 801-290-2847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number7074A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number3099134-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: