Healthcare Provider Details

I. General information

NPI: 1407917107
Provider Name (Legal Business Name): ASPEN DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E 800 N
SPANISH FORK UT
84660-1209
US

IV. Provider business mailing address

114 E 800 N
SPANISH FORK UT
84660-1209
US

V. Phone/Fax

Practice location:
  • Phone: 801-794-1490
  • Fax: 801-794-1495
Mailing address:
  • Phone: 801-794-1490
  • Fax: 801-794-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number179077-1204
License Number StateUT

VIII. Authorized Official

Name: DR. WARREN A PETERSON
Title or Position: OWNER
Credential: DO
Phone: 801-794-1490