Healthcare Provider Details

I. General information

NPI: 1114561883
Provider Name (Legal Business Name): WAYNE OLIVER COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5848 S 300 E
MURRAY UT
84107-6157
US

IV. Provider business mailing address

5848 S 300 E
MURRAY UT
84107-6157
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number8202228-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: