Healthcare Provider Details

I. General information

NPI: 1497725022
Provider Name (Legal Business Name): JARED MOETAO TONGAONEVAI RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MAIN ST
SLC UT
84101-3176
US

IV. Provider business mailing address

2085 E 9100 S
SANDY UT
84093-2525
US

V. Phone/Fax

Practice location:
  • Phone: 801-539-7028
  • Fax:
Mailing address:
  • Phone: 801-792-5358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number5185700-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: