Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | 8281533-4405 | UT |
NPI | 1104307198 |
---|---|
Provider Name | Dallin Douglas Willes |
First Address | Salt Lake City, UT 84132-0001 |
Second Address | Salt Lake City, UT 84132-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/08/2018 |
Last Update Date | 27/08/2018 |