Provider Demographics
NPI:1710909122
Name:NELSON, MICHAEL L (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 W 200 N
Mailing Address - Street 2:SUITE1
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1756
Mailing Address - Country:US
Mailing Address - Phone:801-794-3856
Mailing Address - Fax:801-794-9882
Practice Address - Street 1:65 W 200 N
Practice Address - Street 2:SUITE1
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1756
Practice Address - Country:US
Practice Address - Phone:801-794-3856
Practice Address - Fax:801-794-9882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT367775-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU76469Medicare UPIN
UT005817301Medicare ID - Type Unspecified