Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 291536-1205 | UT |
Y | 207Q00000X | Family Doctor | 2915361205 | UT |
NPI | 1154307197 |
---|---|
Provider Name | Marc O Anderson |
First Address | Layton, UT 84041-0337 |
Second Address | Layton, UT 84041 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2005 |
Last Update Date | 23/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D0994 | (05) | UT |
G06093 | (02) |