Healthcare Provider Details

I. General information

NPI: 1043706146
Provider Name (Legal Business Name): JONATHAN D WILSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 W GORDON AVE STE 1
LAYTON UT
84041-5728
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-397-6150
  • Fax: 801-397-6151
Mailing address:
  • Phone: 801-475-3481
  • Fax: 801-397-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6496499-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: