Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 11099671-1204 | UT |
N | 208D00000X | General Practice Physician | DO187716 | OR |
NPI | 1285080796 |
---|---|
Provider Name | Dr. Hawkins Boone Mecham |
First Address | South Jordan, UT 84009-8721 |
Second Address | South Jordan, UT 84009-8721 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2016 |
Last Update Date | 16/09/2021 |