Healthcare Provider Details

I. General information

NPI: 1023048634
Provider Name (Legal Business Name): LAWRENCE DIXON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

3821 SUNNYDALE DR
SALT LAKE CITY UT
84109-3501
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax: 801-584-5609
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209300-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: