Healthcare Provider Details

I. General information

NPI: 1063824969
Provider Name (Legal Business Name): ART OF MODERN ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 WASHINGTON BLVD STE 105
OGDEN UT
84401-4149
US

IV. Provider business mailing address

PO BOX 1468
BOUNTIFUL UT
84011-1468
US

V. Phone/Fax

Practice location:
  • Phone: 801-392-0385
  • Fax:
Mailing address:
  • Phone: 801-296-2113
  • Fax: 801-296-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2775864406
License Number StateUT

VIII. Authorized Official

Name: MANARDIE FRANCIS SHIMATA
Title or Position: OWNER
Credential: CRNA
Phone: 801-392-0385