Healthcare Provider Details

I. General information

NPI: 1215793799
Provider Name (Legal Business Name): MARTY J JOHNSON NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S 400 E STE 100
BOUNTIFUL UT
84010-4862
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3482
  • Fax:
Mailing address:
  • Phone: 801-475-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11099893-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11099893-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: