Provider Demographics
NPI:1205883576
Name:NILSON, WENDELL TRUMAN (MD)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:TRUMAN
Last Name:NILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 E 100 S STE 14
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-3005
Mailing Address - Country:US
Mailing Address - Phone:435-634-0055
Mailing Address - Fax:435-674-7994
Practice Address - Street 1:1240 E 100 S STE 14
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-3005
Practice Address - Country:US
Practice Address - Phone:435-634-0055
Practice Address - Fax:435-674-7994
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT167758-1205208000000X
UT204952-4405363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics