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General NPI Number Information
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NPI Number | 1003425356
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Entity Type | Individual
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Provider Name | MATTHEW WESTON POMMERVILLE FNP
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Gender | Male
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Dates
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Enumeration Date | 07/23/2020
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Last Update Date | 02/18/2021
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Provider Practice Location Address
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Address Line | 1600 SNOW CREEK DR
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City | PARK CITY
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State | UT
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Zip | 84060-7372
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Country | US
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Telephone | 435-655-0055
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Fax | 435-655-8979
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Provider Business Mailing Address
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Address Line | PO BOX 198560
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City | ATLANTA
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State | GA
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Zip | 30384-8560
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 8038057-4405
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License Number State | UT
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