Provider Demographics
NPI:1548366552
Name:ASTLE, NELSON L (MD)
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:L
Last Name:ASTLE
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 1:1477 NORTH 2000 WEST
Mailing Address - Street 2:SUITE C
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-9099
Mailing Address - Country:US
Mailing Address - Phone:801-774-8888
Mailing Address - Fax:801-825-8519
Practice Address - Street 1:1477 N 2000 W
Practice Address - Street 2:SUITE C
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-9099
Practice Address - Country:US
Practice Address - Phone:801-774-8888
Practice Address - Fax:801-825-8519
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1717961205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A01980Medicare UPIN
UT000011039Medicare ID - Type Unspecified