Healthcare Provider Details

I. General information

NPI: 1013522564
Provider Name (Legal Business Name): MALE FERTILITY AND PEYRONIE'S CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1443 W 800 N STE 302
OREM UT
84057-2883
US

IV. Provider business mailing address

1443 W 800 N STE 302
OREM UT
84057-2883
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-0015
  • Fax: 801-655-0048
Mailing address:
  • Phone: 801-655-0015
  • Fax: 801-655-0048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LANDON TROST
Title or Position: OWNER, MD
Credential: MD
Phone: 801-655-0015