Healthcare Provider Details

I. General information

NPI: 1982148581
Provider Name (Legal Business Name): RUSSELL DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2016
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 AARON DR STE B
TOOELE UT
84074-8138
US

IV. Provider business mailing address

1887 N AARON DR SUITE B
TOOELE UT
84074
US

V. Phone/Fax

Practice location:
  • Phone: 435-775-9969
  • Fax:
Mailing address:
  • Phone: 435-775-9969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4988445-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: