Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | 151881-1205 | UT |
NPI | 1073776787 |
---|---|
Provider Name | Dr. John Clark Nelson |
First Address | Centerville, UT 84014-2826 |
Second Address | Centerville, UT 84014-2826 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2008 |
Last Update Date | 03/07/2008 |