Healthcare Provider Details

I. General information

NPI: 1881185247
Provider Name (Legal Business Name): DEREK JOHN SHARP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S FASHION BLVD, BLDG #5, SUITE 210
MURRAY UT
84107
US

IV. Provider business mailing address

7676 S RIVERWOOD DR
SANDY UT
84093-6134
US

V. Phone/Fax

Practice location:
  • Phone: 208-221-9590
  • Fax:
Mailing address:
  • Phone: 208-221-9590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number6328151-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: