Healthcare Provider Details

I. General information

NPI: 1871976985
Provider Name (Legal Business Name): MT. TIMPANOGAS FERTILITY & ENDOCRINOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 E 9400 S STE 112
SANDY UT
84094-4134
US

IV. Provider business mailing address

880 E 9400 S STE 112
SANDY UT
84094-4134
US

V. Phone/Fax

Practice location:
  • Phone: 801-938-9627
  • Fax: 801-666-6915
Mailing address:
  • Phone: 801-938-9627
  • Fax: 801-666-6915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6814504-1206
License Number StateUT

VIII. Authorized Official

Name: HANSEL RAYNER
Title or Position: OWNER
Credential:
Phone: 801-938-9627