Provider Demographics
NPI:1902380280
Name:NIELSON, ROBERT LYLE (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LYLE
Last Name:NIELSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S 200 W
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-1740
Mailing Address - Country:US
Mailing Address - Phone:435-660-0475
Mailing Address - Fax:
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-623-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7893551-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty