Healthcare Provider Details

I. General information

NPI: 1023504032
Provider Name (Legal Business Name): SETH S WAYNE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S CHIPETA WAY STE 22
SALT LAKE CITY UT
84108-1234
US

IV. Provider business mailing address

295 S CHIPETA WAY STE 22
SALT LAKE CITY UT
84108-1234
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7766
  • Fax: 801-581-5807
Mailing address:
  • Phone: 801-581-7766
  • Fax: 801-581-5807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number14225062-4810
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: