Healthcare Provider Details

I. General information

NPI: 1104658749
Provider Name (Legal Business Name): DEREK MOOS AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2977 WEST 2600 SOUTH
SYRACUSE UT
84075
US

IV. Provider business mailing address

2977 WEST 2600 SOUTH
SYRACUSE UT
84075
US

V. Phone/Fax

Practice location:
  • Phone: 801-682-6170
  • Fax:
Mailing address:
  • Phone: 801-682-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number6586693-4405
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: