Healthcare Provider Details

I. General information

NPI: 1740687086
Provider Name (Legal Business Name): MR. STEPHEN PATRICK ESCOBAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 VILLAGE DR DEPT 2801
OGDEN UT
84408-3674
US

IV. Provider business mailing address

1655 E 2700 S
SALT LAKE CITY UT
84106-3674
US

V. Phone/Fax

Practice location:
  • Phone: 801-626-6000
  • Fax:
Mailing address:
  • Phone: 301-520-8933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: