Provider Demographics
NPI:1912384637
Name:NIELSEN, KYLE EARL (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:EARL
Last Name:NIELSEN
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 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:435-251-1000
Mailing Address - Fax:
Practice Address - Street 1:2292 N 1430 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:013-105-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR7547207P00000X
UT12425915-1204207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390200000XOtherSTUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM