Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 11450132-1205 | UT |
Y | 208600000X | Surgeon | 11450132-1205 | UT |
NPI | 1013371822 |
---|---|
Provider Name | Dr. Travis Corgan |
First Address | Salt Lake City, UT 84132-0002 |
Second Address | Salt Lake City, UT 84132-0002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2016 |
Last Update Date | 11/09/2019 |