Healthcare Provider Details

I. General information

NPI: 1720341837
Provider Name (Legal Business Name): JOSE LUIS ESPARZA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 S 400 E
SALT LAKE CITY UT
84111-3302
US

IV. Provider business mailing address

4427 S LAGO GRANDE DR
WEST VALLEY CITY UT
84128-5632
US

V. Phone/Fax

Practice location:
  • Phone: 801-539-8617
  • Fax:
Mailing address:
  • Phone: 801-967-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5662869-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: