Healthcare Provider Details

I. General information

NPI: 1073552519
Provider Name (Legal Business Name): PETER CHRISTIAN NIELSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 10TH AVE #100
SALT LAKE CITY UT
84103-2853
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-408-8399
  • Fax: 801-408-5152
Mailing address:
  • Phone: 801-408-8399
  • Fax: 801-408-5152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number49722151205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: