Healthcare Provider Details

I. General information

NPI: 1356636443
Provider Name (Legal Business Name): RUSSELL B PINCOCK NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S 300 W
BLANDING UT
84511-3921
US

IV. Provider business mailing address

PO BOX 130
MONTEZUMA CREEK UT
84534-0130
US

V. Phone/Fax

Practice location:
  • Phone: 435-651-3700
  • Fax: 435-678-0608
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number49201274405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: