MEDICARE: GREGORY G NELSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	328625-2401	UT

General Provider Information

NPI Number	:	1568841245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY G NELSON

Provider Business Mailing Address
First Line	:	3257 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2246
Country	:	US
Telephone Number	:	801-716-2289
Fax Number	:

Provider Business Practice Location Address
First Line	:	3257 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2246
Country	:	US
Telephone Number	:	801-716-2289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2015
Last Update Date	:	05/27/2015

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