Healthcare Provider Details

I. General information

NPI: 1205883576
Provider Name (Legal Business Name): WENDELL TRUMAN NILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 E 100 S STE 14
SAINT GEORGE UT
84790-3005
US

IV. Provider business mailing address

1240 E 100 S STE 14
SAINT GEORGE UT
84790-3005
US

V. Phone/Fax

Practice location:
  • Phone: 435-634-0055
  • Fax: 435-674-7994
Mailing address:
  • Phone: 435-634-0055
  • Fax: 435-674-7994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number167758-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number204952-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: