Healthcare Provider Details

I. General information

NPI: 1821752676
Provider Name (Legal Business Name): MARK DUWAYNE DEIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6154 S 2175 E
OGDEN UT
84403-5354
US

IV. Provider business mailing address

6154 S 2175 E
OGDEN UT
84403-5354
US

V. Phone/Fax

Practice location:
  • Phone: 801-726-3738
  • Fax:
Mailing address:
  • Phone: 801-726-3738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5663497-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number56634973102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: