Provider Demographics
NPI:1235232307
Name:NELSON, DEVON A (MD)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:A
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 121
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-373-7350
Practice Address - Fax:801-812-5401
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT1570391205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQM000056634OtherALTIUS
UT870281028000Medicaid
UT870281028DEVOtherEMIA
UT68076OtherPEHP
UT09-00408OtherUTAH HEALTHCARE
UT35973OtherDMBA
UT107006216103OtherIHC
UT200045121OtherPALMETTO
UT870281028000Medicaid
UT107006216103OtherIHC
UT0651550002Medicare NSC
UT007325Medicare UPIN