Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 9888137-4810 | UT |
NPI | 1083128730 |
---|---|
Provider Name | Kia Wilson |
First Address | Ogden, UT 84403-5298 |
Second Address | Salt Lake City, UT 84108-1260 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/11/2017 |
Last Update Date | 27/12/2021 |