Provider Demographics
NPI:1154179844
Name:NIELSEN, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 S 1520 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-5881
Mailing Address - Country:US
Mailing Address - Phone:801-995-1704
Mailing Address - Fax:
Practice Address - Street 1:932 S 1520 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84059-5881
Practice Address - Country:US
Practice Address - Phone:801-995-1704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program