Healthcare Provider Details

I. General information

NPI: 1750914446
Provider Name (Legal Business Name): NICK BLAINE LAYTON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5097 S 900 E STE 100
MURRAY UT
84117-5725
US

IV. Provider business mailing address

6654 S STONE MILL DR
SALT LAKE CITY UT
84121-3494
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-5554
  • Fax: 833-464-2575
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number11057552-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11057552-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: