Healthcare Provider Details

I. General information

NPI: 1902380280
Provider Name (Legal Business Name): ROBERT LYLE NIELSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 W 1500 N
NEPHI UT
84648-8900
US

IV. Provider business mailing address

220 S 200 W
NEPHI UT
84648-1740
US

V. Phone/Fax

Practice location:
  • Phone: 435-623-3000
  • Fax:
Mailing address:
  • Phone: 435-660-0475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7893551-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: