Healthcare Provider Details

I. General information

NPI: 1760677686
Provider Name (Legal Business Name): EVAN J MATHESON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 N 500 W # 200
PROVO UT
84601-1472
US

IV. Provider business mailing address

745 N 500 W # 200
PROVO UT
84601-1472
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-9292
  • Fax: 801-375-9290
Mailing address:
  • Phone: 801-375-9292
  • Fax: 801-375-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EVAN J MATHESON
Title or Position: OWNER
Credential: M.D.
Phone: 801-375-9292