Healthcare Provider Details

I. General information

NPI: 1942892815
Provider Name (Legal Business Name): SCOTT GWILLIAM FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 BURR CT
LAFAYETTE CA
94549-5504
US

IV. Provider business mailing address

3 BURR CT
LAFAYETTE CA
94549-5504
US

V. Phone/Fax

Practice location:
  • Phone: 801-367-1318
  • Fax:
Mailing address:
  • Phone: 801-367-1318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95016644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: