Provider Demographics
NPI:1679119242
Name:LUND, NIELS
Entity type:Individual
Prefix:
First Name:NIELS
Middle Name:
Last Name:LUND
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 1:1870 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3414
Mailing Address - Country:US
Mailing Address - Phone:817-271-3303
Mailing Address - Fax:
Practice Address - Street 1:14 ARAPAHO ROAD
Practice Address - Street 2:
Practice Address - City:ARAPAHOE
Practice Address - State:WY
Practice Address - Zip Code:82510-0014
Practice Address - Country:US
Practice Address - Phone:307-856-9281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11393353-2401225100000X
WYPT-1923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1679119242Medicaid