Healthcare Provider Details

I. General information

NPI: 1700305265
Provider Name (Legal Business Name): MOLLI A NEILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 09/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3075
  • Fax: 801-475-3076
Mailing address:
  • Phone: 801-475-3075
  • Fax: 801-475-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7773064-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: