Provider Demographics
NPI:1790756815
Name:NIELSON, ADAM SANFORD (MD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:SANFORD
Last Name:NIELSON
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 1:250 W 300 N
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2351
Mailing Address - Country:US
Mailing Address - Phone:719-282-8710
Mailing Address - Fax:719-282-8710
Practice Address - Street 1:250 W 300 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2351
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:435-722-9291
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60130455207P00000X
NE23355208D00000X
UT10104037-1205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1790756815Medicaid
WA1790756815Medicaid
WA1790756815Medicaid