Healthcare Provider Details

I. General information

NPI: 1215464268
Provider Name (Legal Business Name): ANDREW WILSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2017
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 W 12600 S
RIVERTON UT
84065-7215
US

IV. Provider business mailing address

PO BOX 3570
SALT LAKE CITY UT
84110-3570
US

V. Phone/Fax

Practice location:
  • Phone: 801-727-2056
  • Fax: 770-701-6676
Mailing address:
  • Phone: 801-727-2056
  • Fax: 303-780-0787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDR.0065653
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number12994458-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: