Healthcare Provider Details

I. General information

NPI: 1578926861
Provider Name (Legal Business Name): AMANDA JOHNSON-BAZIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

V. Phone/Fax

Practice location:
  • Phone: 651-207-3255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number13348453-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: