Healthcare Provider Details

I. General information

NPI: 1740086891
Provider Name (Legal Business Name): ANDREW SEGALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

IV. Provider business mailing address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-7025
  • Fax:
Mailing address:
  • Phone: 801-587-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number11457852-4810
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: