Basic Information
| Provider Information | |||||||||
| NPI: | 1679940332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOL | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N 300 W | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841031215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014637415 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 333 N 300 W | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841031215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014637415 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2015 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 20A16120 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 009150 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.