Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 1098541205 | UT |
NPI | 1003822909 |
---|---|
Provider Name | Wayne O Brown |
First Address | Salt Lake City, UT 84127-0128 |
Second Address | Fillmore, UT 84631-5134 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2006 |
Last Update Date | 15/06/2010 |