Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 3259971205 | UT |
NPI | 1023057098 |
---|---|
Provider Name | Justin F Thulin |
First Address | Salt Lake Cty, UT 84124-1259 |
Second Address | Salt Lake City, UT 84124-1216 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2006 |
Last Update Date | 26/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
9311824424 | TAX ID NUMBER (01) | UT |
G30500 | (02) | UT |