Healthcare Provider Details

I. General information

NPI: 1265093785
Provider Name (Legal Business Name): CASEY CRANOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 S REDWOOD RD
SALT LAKE CITY UT
84104-3539
US

IV. Provider business mailing address

15373 S ORISKANY LN
BLUFFDALE UT
84065-2129
US

V. Phone/Fax

Practice location:
  • Phone: 801-875-3031
  • Fax:
Mailing address:
  • Phone: 801-875-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5104652-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: