=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093817884
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC ALFARO APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 12/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 W BROADWAY APT 2106
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84101-3223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-831-8141
-----------------------------------------------------
Fax | 866-382-8761
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2561 S 1560 W STE B
-----------------------------------------------------
City | WOODS CROSS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84087-2361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-505-0821
-----------------------------------------------------
Fax | 801-942-5955
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 58988864405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 5898886-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------