Healthcare Provider Details

I. General information

NPI: 1629696794
Provider Name (Legal Business Name): NATHANIEL WALTER OSWALD MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W COUGAR BLVD STE 704
PROVO UT
84604-3333
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 866-415-6556
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberR78158
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number390200000X
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number14213554-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: