Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 12094429-1204 | UT |
NPI | 1003479213 |
---|---|
Provider Name | Justin Scott Coles |
First Address | Ogden, UT 84403-3295 |
Second Address | Ogden, UT 84403-3295 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2019 |
Last Update Date | 18/01/2021 |