Provider Demographics
NPI:1912617473
Name:NELSON, ANDREW JOSEPH
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOSEPH
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4981 S 4900 W
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-6316
Mailing Address - Country:US
Mailing Address - Phone:801-430-0954
Mailing Address - Fax:
Practice Address - Street 1:607 E 200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2110
Practice Address - Country:US
Practice Address - Phone:801-430-0954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-24
Last Update Date:2022-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11273261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0807673823Medicaid