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General NPI Number Information
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NPI Number | 1700311560
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Entity Type | Individual
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Provider Name | STANTON NIELSEN JR. D.O.
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Gender | Male
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Dates
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Enumeration Date | 04/28/2017
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Last Update Date | 07/24/2023
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Provider Practice Location Address
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Address Line | 2650 RIDGE AVE STE 1304
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City | EVANSTON
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State | IL
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Zip | 60201-1700
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Country | US
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Telephone | 480-338-1585
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Fax |
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Provider Business Mailing Address
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Address Line | 180 HARVESTER DR STE 110
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City | BURR RIDGE
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State | IL
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Zip | 60527-6686
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036.163773
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License Number State | IL
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