Healthcare Provider Details

I. General information

NPI: 1962853432
Provider Name (Legal Business Name): NICHOLAS J. PAULK MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 E 3900 S STE 100
SALT LAKE CITY UT
84124-1550
US

IV. Provider business mailing address

1521 E 3900 S STE 100
SALT LAKE CITY UT
84124-1550
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-3800
  • Fax: 801-268-3997
Mailing address:
  • Phone: 801-268-3800
  • Fax: 801-268-3997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number7872137-1205
License Number StateUT

VIII. Authorized Official

Name: NICHOLAS JAMES PAULK
Title or Position: PRESIDENT
Credential: MD
Phone: 801-268-3800