Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 10320622-1202 | UT |
NPI | 1356820609 |
---|---|
Provider Name | Jared Wadsworth |
First Address | Provo, UT 84604-1584 |
Second Address | Provo, UT 84604-8460 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2018 |
Last Update Date | 08/08/2018 |