Provider Demographics
NPI:1316195944
Name:NILSSON, MARK WILLIAM (BS BC-HIS)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:NILSSON
Suffix:
Gender:M
Credentials:BS BC-HIS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1770 RED CLIFFS DR
Mailing Address - Street 2:214
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-8144
Mailing Address - Country:US
Mailing Address - Phone:435-628-3192
Mailing Address - Fax:435-628-2237
Practice Address - Street 1:1770 RED CLIFFS DR
Practice Address - Street 2:214
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8144
Practice Address - Country:US
Practice Address - Phone:435-628-3192
Practice Address - Fax:435-628-2237
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1012074601237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870429766000Medicaid