Healthcare Provider Details

I. General information

NPI: 1194216895
Provider Name (Legal Business Name): EDWIN O AWINDA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 S 500 E
SALT LAKE CITY UT
84107-1866
US

IV. Provider business mailing address

1728 S WRIGHT CT
SALT LAKE CITY UT
84105-2914
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-9181
  • Fax: 813-336-8463
Mailing address:
  • Phone: 801-941-4034
  • Fax: 813-366-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number7321629-8900
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7321629-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: