Healthcare Provider Details

I. General information

NPI: 1568996502
Provider Name (Legal Business Name): JONATHAN DANIEL RICKS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N 1000 W
TREMONTON UT
84337-9356
US

IV. Provider business mailing address

905 N 1000 W
TREMONTON UT
84337-9356
US

V. Phone/Fax

Practice location:
  • Phone: 435-207-4500
  • Fax:
Mailing address:
  • Phone: 435-207-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10297498-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: