MEDICARE: MICHAEL FANK JR. NP

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	208D00000X	General Practice Physician	8771481	ID
2	208D00000X	General Practice Physician	11401847-4405	UT
3	208D00000X	General Practice Physician	53-84973-081	KS

General Provider Information

NPI Number	:	1477421337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL FANK JR. NP

Provider Business Mailing Address
First Line	:	2504 S IMPERIAL ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3613
Country	:	US
Telephone Number	:	251-767-7880
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 S IMPERIAL ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3613
Country	:	US
Telephone Number	:	251-767-7880
Fax Number	:

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

Provider Enumeration Date	:	10/23/2025
Last Update Date	:	12/05/2025

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