MEDICARE: NICK BLAINE LAYTON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	11057552-1206	UT
2	363A00000X	Physician Assistant	11057552-1206	UT

General Provider Information

NPI Number	:	1750914446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICK BLAINE LAYTON PA

Provider Business Mailing Address
First Line	:	6654 S STONE MILL DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3494
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5097 S 900 E STE 100
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84117-5725
Country	:	US
Telephone Number	:	801-851-5554
Fax Number	:	833-464-2575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	03/27/2024

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Directions to “ NICK BLAINE LAYTON PA” Practice Location

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