Healthcare Provider Details

I. General information

NPI: 1891885489
Provider Name (Legal Business Name): WILLIAM WAYNE CRENSHAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 2100 S
SALT LAKE CITY UT
84119-1401
US

IV. Provider business mailing address

PO BOX 510708
SALT LAKE CITY UT
84151-0708
US

V. Phone/Fax

Practice location:
  • Phone: 801-887-2400
  • Fax:
Mailing address:
  • Phone: 801-587-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5904853-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: