Healthcare Provider Details

I. General information

NPI: 1790827251
Provider Name (Legal Business Name): CASEY R NELSON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-1100
US

IV. Provider business mailing address

PO BOX 3208
SALT LAKE CITY UT
84110-3208
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-6340
  • Fax: 801-587-6346
Mailing address:
  • Phone: 801-587-6340
  • Fax: 801-587-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7331309-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004935
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: