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General NPI Number Information
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NPI Number | 1881954634
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Entity Type | Individual
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Provider Name | MARK WILSON THOMAS DO
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Gender | Male
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Dates
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Enumeration Date | 05/25/2012
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Last Update Date | 01/16/2025
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Provider Practice Location Address
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Address Line | 1034 N 500 W
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City | PROVO
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State | UT
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Zip | 84604
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Country | US
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Telephone | 208-360-3560
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Fax |
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Provider Business Mailing Address
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Address Line | 334 W 800 S
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City | SALEM
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State | UT
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Zip | 84653-5611
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Country | US
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Telephone | 208-360-3560
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | MED-PHYS-LIC-47547
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 02004574A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | DO222639
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 12106328-1204
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License Number State | UT
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