Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0300X | Geriatric Medicine | 5956337-1205 | UT |
NPI | 1083638308 |
---|---|
Provider Name | Dr. Mark Andrew Supiano |
First Address | Salt Lake City, UT 84132-0002 |
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 | 27/07/2006 |
Last Update Date | 23/11/2021 |