Healthcare Provider Details

I. General information

NPI: 1649264664
Provider Name (Legal Business Name): EMMETT WAYNE SEXTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 E FISH HATCHERY RD
MANTUA UT
84324-4379
US

IV. Provider business mailing address

PO BOX 27688 SALT LAKE CITY
SALT LAKE CITY UT
84127-0688
US

V. Phone/Fax

Practice location:
  • Phone: 435-225-5836
  • Fax:
Mailing address:
  • Phone: 801-534-1360
  • Fax: 801-366-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number216299-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: