Basic Information
| Provider Information | |||||||||
| NPI: | 1881635761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POULSEN | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
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| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014298150 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W 800 N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840576301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012245373 | ||||||||
| FaxNumber: | 8012245337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 43447 | KY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 4725374-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.