Basic Information
| Provider Information | |||||||||
| NPI: | 1992903173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POULSON | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3570 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017272056 | ||||||||
| FaxNumber: | 7707016675 | ||||||||
| Practice Location | |||||||||
| Address1: | 8TH AVENUE C ST E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841432360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014981100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MT191516 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 12052769-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.