Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 8183823-4405 | UT |
NPI | 1003586876 |
---|---|
Provider Name | Alisa Corry |
First Address | Draper, UT 84020-1506 |
Second Address | Murray, UT 84107-5718 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2021 |
Last Update Date | 18/10/2021 |