Healthcare Provider Details

I. General information

NPI: 1164802062
Provider Name (Legal Business Name): JASON DEAN NEILSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 09/15/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E MAIN ST
SANTAQUIN UT
84655
US

IV. Provider business mailing address

210 E MAIN ST
SANTAQUIN UT
84655
US

V. Phone/Fax

Practice location:
  • Phone: 435-623-3616
  • Fax: 801-754-3322
Mailing address:
  • Phone: 435-623-3616
  • Fax: 801-754-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number9832794-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9832794-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: