Provider Demographics
NPI:1942784962
Name:NELSEN, KATIE MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MAE
Last Name:NELSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1969 E MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2959
Mailing Address - Country:US
Mailing Address - Phone:951-818-2989
Mailing Address - Fax:
Practice Address - Street 1:3556 W 9800 S STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3221
Practice Address - Country:US
Practice Address - Phone:801-567-9780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant