Healthcare Provider Details

I. General information

NPI: 1063256659
Provider Name (Legal Business Name): DANIEL MILES FIDLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 2100 S
SALT LAKE CITY UT
84119-1407
US

IV. Provider business mailing address

1525 W 2100 S
SALT LAKE CITY UT
84119-1407
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-9900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14024734-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: