Provider Demographics
NPI:1508844853
Name:MCKELLAR, NATHAN C (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:C
Last Name:MCKELLAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-840-2000
Mailing Address - Fax:
Practice Address - Street 1:3845 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-3454
Practice Address - Country:US
Practice Address - Phone:801-840-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9335759-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508844853Medicaid
IA7291351Medicaid
IAP00360624OtherRR MEDICARE
IA5291351Medicaid
IA6291351Medicaid
IA8291351Medicaid
IAI15477Medicare PIN
IAH95837Medicare UPIN
IAP00338797OtherRR MEDICARE