Basic Information
| Provider Information | |||||||||
| NPI: | 1518057124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 58049 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841580049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 CIRCLE OF HOPE DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841125550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015850111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 158217-1205 | UT | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 757023028 | 01 | UT | RAILROAD MEDICARE | OTHER | 188833 | 05 | AZ | MEDICAID | 003065200 | 05 | ID | MEDICAID | XPY044510 | 05 | CA | MEDICAID |