Provider Demographics
NPI:1992903173
Name:POULSON, NATHAN A (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:POULSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3570
Mailing Address - Country:US
Mailing Address - Phone:801-727-2056
Mailing Address - Fax:770-701-6675
Practice Address - Street 1:8TH AVENUE C ST E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-2360
Practice Address - Country:US
Practice Address - Phone:801-498-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT191516207L00000X
UT12052769-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology