Provider Demographics
NPI:1972178523
Name:NIELSEN, NATHANIEL RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:RICHARD
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7080 W SANNA ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8898
Mailing Address - Country:US
Mailing Address - Phone:208-406-6573
Mailing Address - Fax:
Practice Address - Street 1:7080 W SANNA ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8898
Practice Address - Country:US
Practice Address - Phone:208-406-6573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZOPT-002514152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program