Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 8695316-4405 | UT |
NPI | 1083108872 |
---|---|
Provider Name | Matthew Thomas Anderson |
First Address | Taylorsville, UT 84129-1353 |
Second Address | Salt Lake City, UT 84113-1125 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2018 |
Last Update Date | 15/06/2018 |