Healthcare Provider Details

I. General information

NPI: 1033729512
Provider Name (Legal Business Name): JUSTIN ROBERT HASLAM NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 CRESTWOOD DR
OGDEN UT
84405-4869
US

IV. Provider business mailing address

5740 CRESTWOOD DR
OGDEN UT
84405-4869
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-7771
  • Fax: 801-479-7795
Mailing address:
  • Phone: 801-479-7771
  • Fax: 801-479-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9137974-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: