Basic Information
| Provider Information | |||||||||
| NPI: | 1275639122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NILSON | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10150 CENTENNIAL PKWY STE 230 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840704123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005945736 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10150 CENTENNIAL PKWY STE 230 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840704123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005945736 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G-83928 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 366647-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 7151 | 01 | UT | HEALTHY U | OTHER | 425650 | 01 | UT | DESERET MUTUAL | OTHER | PRA02246 | 01 | UT | MOLINA | OTHER | 107008628103 | 01 | UT | IHC | OTHER | 66104 | 01 | UT | PEHP | OTHER | QM0000054865 | 01 | UT | ALTIUS | OTHER | 870666269JTN | 01 | UT | EDUCATORS MUTUAL | OTHER | 190683600 | 01 | UT | US DEPT OF LABOR | OTHER |