MEDICARE: MR. RANDALL CHARLES HIPWELL ACNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	377763-4405	UT

General Provider Information

NPI Number	:	1114173762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDALL CHARLES HIPWELL ACNP-C

Provider Business Mailing Address
First Line	:	2733 HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3144
Country	:	US
Telephone Number	:	801-652-9377
Fax Number	:	801-581-4999

Provider Business Practice Location Address
First Line	:	2733 HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3144
Country	:	US
Telephone Number	:	801-652-9377
Fax Number	:	801-581-4999

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2008
Last Update Date	:	08/14/2008

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