=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396557310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLEMAN LANE BARNSON PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2025
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W LAYTON PKWY
-----------------------------------------------------
City | LAYTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84041-3692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-543-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 HARRISON BLVD
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-3195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-387-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------