Healthcare Provider Details

I. General information

NPI: 1063771475
Provider Name (Legal Business Name): SAGE RYLANT UKENA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 ADAMS AVE
OGDEN UT
84401-1511
US

IV. Provider business mailing address

2240 ADAMS AVE
OGDEN UT
84401-1511
US

V. Phone/Fax

Practice location:
  • Phone: 801-393-5355
  • Fax: 801-394-4609
Mailing address:
  • Phone: 801-393-5355
  • Fax: 801-394-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number66952204405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: