Healthcare Provider Details

I. General information

NPI: 1306378823
Provider Name (Legal Business Name): MICHAEL K NEILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W 940 N
PROVO UT
84604-3301
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7871
  • Fax:
Mailing address:
  • Phone: 801-357-7871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11680858-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number11680858-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: