Provider Demographics
NPI:1013703032
Name:FOX-NIKOLAEV, ROMAN
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:FOX-NIKOLAEV
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E 300 S APT 410
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2655 S LAKE ERIE DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-7350
Practice Address - Country:US
Practice Address - Phone:385-441-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker