Healthcare Provider Details

I. General information

NPI: 1891802591
Provider Name (Legal Business Name): TAWNYA M. CONSTANTINO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 COTTONWOOD ST SUITE 810
MURRAY UT
84107-5704
US

IV. Provider business mailing address

5171 COTTONWOOD ST SUITE 810
MURRAY UT
84107-5704
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-9800
  • Fax: 801-507-9801
Mailing address:
  • Phone: 801-507-9800
  • Fax: 801-507-9801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number312149-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: