1316195944 NPI number — MR. MARK WILLIAM NILSSON B.S. BC-HIS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316195944 NPI number — MR. MARK WILLIAM NILSSON B.S. BC-HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NILSSON
Provider First Name:
MARK
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
B.S. BC-HIS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316195944
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1770 RED CLIFFS DR
Provider Second Line Business Mailing Address:
214
Provider Business Mailing Address City Name:
ST GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84790-8144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-628-3192
Provider Business Mailing Address Fax Number:
435-628-2237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1770 RED CLIFFS DR
Provider Second Line Business Practice Location Address:
214
Provider Business Practice Location Address City Name:
ST GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84790-8144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-628-3192
Provider Business Practice Location Address Fax Number:
435-628-2237
Provider Enumeration Date:
09/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  1012074601 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 870429766000 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com