Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 209300-4405 | UT |
NPI | 1023048634 |
---|---|
Provider Name | Mr. Lawrence Dixon |
First Address | Salt Lake City, UT 84109-3501 |
Second Address | Salt Lake City, UT 84148-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2006 |
Last Update Date | 08/07/2007 |