=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144497322
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC TRAVIS NUTTALL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2008
-----------------------------------------------------
Last Update Date | 08/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 N 500 W STE 202
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84604-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-374-2367
-----------------------------------------------------
Fax | 801-429-8015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1055 N 500 W ATTN: CREDENTIALING
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84604-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-354-8225
-----------------------------------------------------
Fax | 801-418-0941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 6805182-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 68050182-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------