Healthcare Provider Details

I. General information

NPI: 1407164213
Provider Name (Legal Business Name): ZACHARY TAYLOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 401
PROVO UT
84604-3306
US

IV. Provider business mailing address

1583 E 1060 N
LEHI UT
84043-1484
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7499
  • Fax: 801-373-5980
Mailing address:
  • Phone: 801-376-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5251843-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: