Healthcare Provider Details

I. General information

NPI: 1821841594
Provider Name (Legal Business Name): AUSTIN RAY SIMISTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18701 N 67TH AVE
GLENDALE AZ
85308-7100
US

IV. Provider business mailing address

151 N 50 E
COALVILLE UT
84017-5500
US

V. Phone/Fax

Practice location:
  • Phone: 623-561-1000
  • Fax:
Mailing address:
  • Phone: 435-901-4312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: