=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598072332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN A STOUT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2010
-----------------------------------------------------
Last Update Date | 08/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7655 S 2700 W APT. B
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84084-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-540-0688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7655 S 2700 W APT. B
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84084-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 69840251702
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------