Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 123456-1205 | UT |
N | 2081S0010X | Sports Medicine | 123456-1205 | UT |
N | 213ES0000X | Sports Medicine | 123456-1205 | UT |
NPI | 1497168272 |
---|---|
Provider Name | Jared Takeshi Aida |
First Address | Woods Cross, UT 84087-2361 |
Second Address | Salt Lake City, UT 84124-1264 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2014 |
Last Update Date | 23/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12573316-1204 | LICENSE (01) | UT |