Healthcare Provider Details

I. General information

NPI: 1073061313
Provider Name (Legal Business Name): MATTHEW DAVID NEWBURY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W 800 N
OREM UT
84057-3660
US

IV. Provider business mailing address

PO BOX 3750
SALT LAKE CITY UT
84110-3750
US

V. Phone/Fax

Practice location:
  • Phone: 801-714-6000
  • Fax:
Mailing address:
  • Phone: 800-748-4868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7285946-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: