Provider Demographics
NPI:1881635761
Name:POULSEN, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:POULSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:
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:801-429-8150
Practice Address - Street 1:700 W 800 N
Practice Address - Street 2:SUITE 100
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-6301
Practice Address - Country:US
Practice Address - Phone:801-224-5373
Practice Address - Fax:801-224-5337
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43447207X00000X
UT4725374-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery