Healthcare Provider Details

I. General information

NPI: 1407036189
Provider Name (Legal Business Name): COTTONTREE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 N UNIVERSITY PKWY SUITE 1A
PROVO UT
84604-1509
US

IV. Provider business mailing address

2230 N UNIVERSITY PKWY SUITE 1A
PROVO UT
84604-1509
US

V. Phone/Fax

Practice location:
  • Phone: 801-377-3413
  • Fax: 801-655-1890
Mailing address:
  • Phone: 801-377-3413
  • Fax: 801-655-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateUT

VIII. Authorized Official

Name: SHAUNA MANHART
Title or Position: MANAGER
Credential:
Phone: 801-377-3413