MEDICARE: FAYE MITSUNAGA M.A., CCC-A

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	231H00000X	Audiologist	324350-4101	UT

General Provider Information

NPI Number	:	1316283815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAYE MITSUNAGA M.A., CCC-A

Provider Business Mailing Address
First Line	:	777 E 4500 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-3067
Country	:	US
Telephone Number	:	801-268-6497
Fax Number	:	801-268-1376

Provider Business Practice Location Address
First Line	:	777 E 4500 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-3067
Country	:	US
Telephone Number	:	801-268-6497
Fax Number	:	801-268-1376

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

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	01/02/2013

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