Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 3740151202 | UT |
NPI | 1508947367 |
---|---|
Provider Name | Dr. Robert Jay Shetlin |
First Address | West Jordan, UT 84088-6351 |
Second Address | West Jordan, UT 84088-5126 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/10/2006 |
Last Update Date | 12/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U78292 | (02) | UT |