Provider Demographics
NPI:1073557583
Name:ELIASON, NATHAN B (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:B
Last Name:ELIASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 W 5300 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5671
Mailing Address - Country:US
Mailing Address - Phone:801-327-8700
Mailing Address - Fax:801-290-2847
Practice Address - Street 1:677 W 5300 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5671
Practice Address - Country:US
Practice Address - Phone:801-327-8700
Practice Address - Fax:801-290-2847
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7074A174400000X
UT3099134-1205207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPENDINGMedicaid
WY10313Medicare ID - Type Unspecified