Healthcare Provider Details

I. General information

NPI: 1851822829
Provider Name (Legal Business Name): AUSTIN JAMES WOOLLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 N STATE ST
PROVO UT
84604-1010
US

IV. Provider business mailing address

1735 N STATE ST
PROVO UT
84604-1010
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-1818
  • Fax:
Mailing address:
  • Phone: 801-374-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number12185144-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: