Healthcare Provider Details

I. General information

NPI: 1457682866
Provider Name (Legal Business Name): DZENIS MEHINOVIC CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 11/20/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9660 S 1300 E
SANDY UT
84094-3762
US

IV. Provider business mailing address

PO BOX 3570
SALT LAKE CITY UT
84110-3570
US

V. Phone/Fax

Practice location:
  • Phone: 801-727-2056
  • Fax: 770-701-6675
Mailing address:
  • Phone: 801-727-2056
  • Fax: 770-701-6675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP118812
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number084069
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5158976-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: