Provider Demographics
NPI:1114253234
Name:NIELSON, WAYNE S (PA)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:S
Last Name:NIELSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-3260
Mailing Address - Country:US
Mailing Address - Phone:435-644-4179
Mailing Address - Fax:435-644-3588
Practice Address - Street 1:355 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3260
Practice Address - Country:US
Practice Address - Phone:435-644-4179
Practice Address - Fax:435-644-3588
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4893858-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant