Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 9017921 | UT |
Y | 207ND0101X | MOHS-Micrographic Surgeon | 9017921 | UT |
N | 207NS0135X | Procedural Dermatology | 9017921 | UT |
NPI | 1457666562 |
---|---|
Provider Name | Dr. Jared Heaton |
First Address | Bountiful, UT 84010-7254 |
Second Address | Ogden, UT 84405-5417 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2010 |
Last Update Date | 16/12/2019 |